Descriptive Psychopathology in Asylum Case Histories: The case of John Horatio Baldwin

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CAROL BERKENKOTTER/ CRISTINA HANGANU-BRESCH / KIRA DREHER
‘Descriptive Psychopathology’ in Asylum Case
Histories: The Case of John Horatio Baldwin
1. Introduction
Psychiatry in Great Britain at the turn of the 20th century underwent a
nosological paradigm shift strongly influenced by the systematic
efforts of German psychiatrist Emil Kraepelin (1856-1926) to ‘carve
nature at the joints’ by separating mental illnesses into two major
categories, those of thought and those of mood disorders. In the
English-speaking world, Kraepelin’s categories were first debated
academically, but they eventually permeated psychiatric vocabulary
and practice and took on legal and forensic implications as they
became ensconced in regulatory literature. Asylums were still at the
forefront of psychiatric practice in the early 20th century; thus,
documenting the practices of asylum doctors can offer a window into
the early process of adopting the new nosology. In this chapter we
focus on one of the key terms of the Kraeplinian nosology Manic‒
Depressive Insanity (MDI). We analyze its adoption in the clinical
practice of one English asylum (Ticehurst) by looking in detail at the
documented case history of the first patient formally diagnosed as
‘manic-depressive’ at that institution. Our goal was to chart the case
notes documenting that patient’s symptoms longitudinally to see
whether we could discern a pattern exhibiting the main characteristic
of MDI, the cycling between mania, depression, and, occasionally
‘lucid intervals’, a pattern that could be visible in a retrospective
historical analysis, but which attending doctors failed to perceive until
the MDI diagnosis was adopted by the psychiatric community in Great
Britain. We set that analysis against the backdrop of the larger debate
surrounding the new diagnosis category by using the notion of

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‘enregisterment’ described by Wilce as “the process by which a
linguistic register emerges and solidifies as a recognized, ideologically
construed set of forms” (2009: 205). Thus, we are contrasting two
parallel processes pertaining to Kraeplinian enregisterment in
academia and practice using MDI as an illustrative category. In what
follows, we first provide background and context by explaining the
notion of enregisterment as it applies to the shift in psychiatric
vocabulary and practice in the early 20th century. After briefly
describing the Ticehurst Asylum corpus and its value for medical
history and anthropology, we then present the case of John Horatio
Baldwin, as documented at Ticehurst, and our discourse analysis of his
case notes, focusing on documented instances of mania and depression
that provide depth to his case and justify his (late) diagnosis. Finally,
we discuss the results of our analysis by interpreting them as an
illustration of the uptake process that solidified the category of ‘manic
depression’ in the psychiatric vocabulary for the better part of the 20th
century. By ‘uptake’ we mean the process by which a text ‘invites’
interpretation from successive texts that follow it. The question we
raise is why is it that the diagnosis of ‘maniacal depression’ is
employed by Ticehurst physicians so late 1918 when it had been a‒ ‒
term of art in the psychiatric literature nearly two decades earlier?
To answer this question we are enlisting at the theoretical‒
level the concept of ‘enregisterment’ popularized by Agha (2003),‒
who used it to describe the evolution of Standard British English or
Received Pronunciation (RP). Agha defines enregisterment as
“processes through which a linguistic repertoire [i.e. register – our
note] becomes differentiable within a language as a socially
recognized register of forms” (2003: 231). Such processes have
discernible socio-historical roots that can help explain the ever-shifting
‘cultural value’ (2003: 232) assigned to a certain discursive practice.
Drawing upon Agha, Wilce (2008, 2009) points out that analogously
the ‘medical register’ plays a role in the professionalization and
credibility of a group of people or practitioners, such as, for example,
psychiatrists or expert witnesses. At the center of the enregisterment
process for specialized discourses such as that of psychiatry lies the
primacy of classification: “the self-conscious development of a set of

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labels, knit together in hierarchies, uniquely characterizes the self-
invention of the natural sciences in early modernity” (Wilce 2008: 92).
Wilce points out psychiatry’s fascination with natural kinds, stemming
from what he calls its ‘science envy’ (2008: 93). In other words, while
Agha’s enregisterment analysis of ‘received pronunciation’ (RP)
focuses on a speaker’s class affiliation in Britain, Wilce believes a
similar analysis of psychiatric discursive reform should focus on the
‘will to professionalize’ borne out of the envy/frustration experienced
in the context of the apparent success of other natural sciences at the
end of the 19th century. The many texts driving psychiatry’s nosology-
bound enregisterment processes include, according to Wilce, medical
journal articles, hospital records, and psychiatric textbooks. Although
efforts to describe and conceptualize mental illness in a systematic
fashion abounded, they did not succeed until the years after Kraepelin
made a rigorous effort to establish ‘biological taxonomies’ in his 1899
edition of his textbook on clinical psychiatry. Thus, Wilce concludes,
“[T]he Kraepelinian revolution spawned new scientizing [emphasis
ours] uses of language that came to define the psychiatric register.
Registral consequences are still being felt through successive iterations
of the Diagnostic and Statistical Manual of Mental Disorders (DSM),
in use to a greater or lesser extent around the world” (2008: 93-94).
While Agha and Wilce focus on ‘speech chains’ as the main
processes enabling enregisterment,1 we prefer the term ‘uptake’ from
speech-act theory due to its vectorial quality that captures the dynamic
and transformational nature of the process. Following Austin (1962)
and Freadman (2004) we call ‘uptake’ in this context the process
through which an initial document or series of documents becomes
transformed into practice in other words, the path through which a‒
discursive construct, through a series of ‘interpretant texts’
(Freadman), affects psychiatric practice, by which we mean patients’
11A speech chain, which is the main mechanism of social transmission of RP,
according to Agha (2003), is defined as “a historical series of speech events
linked together by the permutation of individuals across speech-act roles in the
following way: the receiver of the message in the (n)th speech event is the
sender of the message in the (n+1)th speech event” (2003: 247). Wilce (2008,
2009) uses the same term to explain enregisterment of psychiatric vocabulary.

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confinement, treatment, and release, doctor’s duties, and institutional
habits. In this case, the uptake that leads to the concept of manic-
depressive insanity becoming ensconced into psychiatric practice in
the first half of the 20th century in Britain would involve the following:
Genre Authors Audience Time frame
Textbook, lectures Emil Kraepelin German-speaking
psychiatrists
1899
English translations Defendorf,
Johnstone
English-speaking
psychiatrists
1902, 1904
Psychiatry textbooks
Academic articles
Psychiatrists,
researchers
English-speaking
psychiatrists
Early 1900s
Clinical practice
genres: medical
certificates,
statements, case
notes, etc.
Practitioners/
clinicians
Asylum/practice
supervisors,
commissioners in
lunacy, other
psychiatrists
Early 1900s
Official
nomenclatures
Professional
organizations
(e.g. Royal
College of
Physicians)
Psychiatrists,
regulators,
legislators
1918
Table 1. Uptake of ‘maniacal-depressive insanity’ diagnosis in British psychiatric
literature and practice.
Although most psychiatrists gradually adopted the Kraeplinean
nomenclature, a practice which provided them with a more systematic
approach to depicting what often seemed like disparate symptoms in
search of a concept, many continued to record those symptoms in
detail in an effort that, as William Sargant (1967) argued, perhaps
reflected a sense of clinical impotence meaning that where cure was
still elusive, the act of recording patient symptoms in minute detail
offered a sense of purpose and supplanted a form of action (writing)
for healing.
We wanted to see how, in everyday practice, psychiatrists
recorded and made sense of the symptoms for a condition manic-‒
depressive insanity what we have elsewhere called ‘symptoms in‒
search of a concept’ (Berkenkotter/Hanganu-Bresch 2011b). The

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corpus of documents from Ticehurst Asylum in Sussex, England
(1845-1917), which we have described in detail elsewhere
(Berkenkotter/Hanganu-Bresch 2011a), offered an excellent
opportunity to document this process. The considerable material
resources and the wealthy clientele of the asylum allowed “the
superintendent and staff physicians to maintain contact with the
individual patients, and to write up these contacts in detail, making it
possible to determine as time went by the trajectories of the‒ ‒
patients’ illnesses over several months or years” (2011a: 226). The
case we are about to describe occurs over the time frame in which the
term manic depressive insanity as a distinct diagnosis is gradually
accepted and adopted by the psychiatric community (previous attempts
at labeling it notwithstanding see Baillarger 1854; Falret 1854).‒
Kraepelin points out two major criteria for distinguishing between
MDI and other kinds of mood disorders (involuntary melancholia):
cycles and lucid intervals. Berrios (1996) adds that a longitudinal
perspective is important too:
Up to the eighteenth century, insanity (lunacy, madness, vesania) was an
opaque concept which predicated of the insane a state of existence, rather than
of mind. The obvious problem with this view was to explain clinical
remissions. For this, the notion of ’ ‘lucid interval’ was created which
accounted for ‘normal’ behavior without abandoning the view that the person
remained mad at a deep level […] Madness itself was only given a temporal
context during the nineteenth century, when ‘time’ became for the first time, a
dimension of mental disorder. Adding a time dimension rendered madness into
a longitudinal process. (1996: 301)
Thus, it is important to discuss the patient’s history in order to
understand how coding it thematically and arranging those themes
chronologically might yield fruitful results.
2. A narrative history of John Horatio Baldwin’s multiple
confinements at Ticehurst, 1911-1925

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The Baldwin case history corpus consists of nearly 70 handwritten
pages, an institutional narrative spanning his multiple confinements at
Ticehurst between June 1911 and his discharge into private care in
November 1925. Baldwin, a 52-year old former wine merchant and
widower, was the first patient at Ticehurst Asylum in England to be
diagnosed as suffering from ‘maniacal depression’ in 1918, although
Herbert Hayes Newington, Baldwin’s chief physician had presciently
identified Baldwin as being most likely a manic depressive patient in
April 1913. Baldwin was admitted to Ticehurst six times over the
course of fourteen years, with only very brief intermissions between
each admission (see the Appendix for a list of all of Baldwin’s
confinements).
We devote the next several pages to presenting an overview of
Baldwin’s mood swings beginning with brief descriptions of his first
and second confinement at Ticehurst from June 1911 to November
1912, and from February 1913 to April 1913 respectively. It is during
this period that the case notes describe some of the more flamboyant
maniacal elements of Baldwin’s behavior and speech.
Necessary for Baldwin’s confinement are two legal testimonies,
or Medical Certificates, written by physicians/experts who attest to the
extremely erratic behaviors and speech having occurred before at other
institutions. These medical certificates describe Baldwin as “having an
‘intense’ manner, lying frequently, being prone to extravagant
spending, and displaying poor impulse control” (George W. Potter
MD, Cheapside, London). They also describe his previous ‘attack of
melancholia’ lasting about two years (DR. Geo. H. Savage, MD, 26
Devonshire Place W.).
Other legal documents written by Ticehurst physicians shortly
after the patient is confined include the Medical Statement written by
Ticehurst’s Medical Superintendent H.H. Newington. This document
has also medico/legal status as it corroborates what the writers of the
medical certificates had testified:
Medical Statement: “He [Baldwin] is excitable, garrulous, and finds it difficult
to keep to the thread of conversation. […] He refers everything to himself and
his own feelings. He says that the ‘Medical Syndicate, Savage [the second
Medical Certificate writer] and Co. have conspired with his son and daughter

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to shut him up for life. He even hopes that his son will fail in his forthcoming
examination as a punishment. He is not of sound mind and judgment: with
respect to Bodily Health and Condition they are both good.” Dated the 30th
Day of June 1911, Signed H.H. Newington.
Together these three documents argue that Baldwin is displaying the
behavior and speech of someone who suffers exultation, excitement,
and grandiosity characteristic of mania. All of these behaviors
constitute a well-detailed description of someone who suffers from
mania, but who also possesses personal idiosyncrasies that play into
this disorder, such as Baldwin’s obsession with the female sex.
Over the course of several months, the case notes by the
Ticehurst physician, Herbert Hayes Newington, chart Baldwin’s
behavior and general mental and physical state, concluding in periodic
‘medical statements’ that “[H]e is not of sound mind & judgment” a‒
speech act in the medico-legal jargon, used arguably in the absence of
a specific diagnosis. This phrase also demonstrates that at the time,
psychiatric terminology was at the cusp between being aligned with
law and being aligned with medical science.
In the case notes Baldwin’s mood changes are documented in
detail, as can be seen in the following entry:
30 April, 1912: He complains of sleeping badly on account of thinking about
Miss Stevenson who he asserts he loves more than anybody in the world. He
asked me why he could not be discharged and I told him it was because he was
not yet the normal Baldwin, as shown by his proposed ridiculous speculations,
the instability of his kaleidoscopic ideas, and the impression he gave others
that he was at times ‘inebriated with his own verbosity’. He denied nothing but
said that he was now fit for discharge and he ought to be allowed to do as he
liked just as a thief who had served his time could return to his thieving ways
until caught again.
A second example of Baldwin’s manic behaviors can be seen in the
case note dated 30 May 1912:
In spite of having an allowance & promising not to exceed, he runs up little
bills while on parole & has pawned his watch. Though he had written his
daughter to tell her that he had pawned his watch to help an exhausted female
home in a carriage, and though his attendant had seen a few days ago the

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actual pawn ticket, he solemnly assured me this morning when I told him that I
know that he had pawned it, that he had sold it to an attendant here who had
left a long time ago, and that it was in America now. Such evasions show a
remarkable weakening of intellect and common sense. Signed, H.H.N.
[Herbert Hayes Newington]
Not only do the case notes depict specific examples of manic
behaviors, but the reader also finds Baldwin’s own correspondence
with family members attesting to his unstable state of mind. One such
example appears in the case notes in a “copy of card addressed to Miss
Baldwin, May 12 1912.” This card is an example of ‘reported speech’
or the direct representation of the patient’s own words.
Am writing Dr. Alexander Mitchell to tell him the result of my proposal to
you. Dr. S. Newington [Samuel Newington] would have been quite agreeable.
After all, I am asking for rights (and not favours) and your brother solely that
he can pass his examination in June is depriving me of them. You speak not
truly when you say you can’t help me. You mean you won’t, & I swear to the
Almighty I ----- you & Disown you although my bounty ---- keep you from the
streets and becoming a harlot […] If I marry again the inhuman conduct of
yourself & brother towards me will be the sole cause.
Placed as it is among the case notes, such examples of reported speech
reinforce the examples in the case notes of Baldwin’s disturbed
ideation during a manic phase. Elsewhere the reader finds
documentation of Baldwin’s depressive episodes. For example,
8 March, 1913: He has had no narcotic for several nights: he continues to be
depressed & anticipates all sorts of calamities, e.g., that his son will break
down and be certified & sent to Virginia Water [Asylum].
As Baldwin moved in and out of the asylum, the circular nature of his
symptoms did not escape the trained eyes of the senior psychiatrist, Dr.
Hayes Newington, who, in April 1913, wrote a lengthy note regarding
the diagnosis of this case, which he deemed as being ‘particularly
interesting’. Newington described in detail Baldwin’s melancholic
moods followed by ‘well’ stages and then ‘maniacal’ behaviors (of
particular concern to him and Baldwin’s son, actually, were Baldwin

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Senior’s tendency to self harm, such as eating glass, as well as his
preoccupation with the fair sex and his masturbatory habits).
Thus, the doctor wonders, “As these symptoms became more
marked the question of diagnosis came to be premier was it‒
melancholia or simply depression as a forerunner of excitement in
manic-depressive insanity?” While Baldwin’s son, citing his father’s
‘disturbing’ behaviors, wants him again ‘certified’, Hayes Newington
seems resistant to the idea, writing:
I have regarded and now still regard certification in this case as a great evil. It
would destroy the patient’s hope of better things, and the change from his easy
and liberal treatment to that which he knows would be entailed of certification
would probably result in an acute break-down. This would be in any case a
disaster, but still more disastrous if it thereby defeated the hope, which I have,
that rest and careful medical treatment will tend to break up the tendency, that
undoubtedly exists, to confirmed manic-depressive insanity. (154-175)
Newington is hesitant to apply the new and ‘interesting’ medical
diagnosis, possibly because of its long-term implications: MDI is a
longitudinal disease with a bleak outcome, and he is still hoping they
were just witnessing curable episodes rather than a lifetime illness.
Still, it is the first time that a Kraeplinian register is encroaching on the
old, vague, all-encompassing label ‘of unsound mind’. This first
attempt to organize symptoms into a diagnosis is not, however,
formalized in either the medical statements or in the medical
certificates until five years later. This may be due to a possible
resistance by Newington to Kraeplinian nomenclature. In 1909, he had
in fact participated in a Medico-Psychological Association meeting
during which he argued against adopting another Kraeplinian category,
‘dementia praecox’. While we cannot extend Hays Newington’s
perspective on dementia praecox to manic-depressive insanity, we can
speculate that a resistance to Kraepelin’s wide-ranging disease groups
could explain his delay in identifying Baldwin’s condition as manic-
depressive insanity for two years after his entry to Ticehurst, as well as
his hesitation to ascribe the new diagnosis formally.
Meanwhile Baldwin is hospitalized again from 1916 through
1918, escapes on July 12, 1918, then is readmitted a few days later on
July 18th the same year. This is when, in the wake of Newington’s

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death in 1917, Newington’s successor, Colin McDowall, rather matter-
of-factly states in the ‘Medical Statement’ that “He is suffering from
maniacal depressive insanity.” While at the moment of his admission
Baldwin is described as being manic (making rash decision, such as
marrying a housemaid in the month during which he was out of the
asylum), he is soon described as ‘depressed’. In fact, McDowall
convincingly notes now that “The depressed phase has begun” (July
25th). The same diagnosis is repeated in the August 19th Medical
Statement:
He is suffering from maniacal depressive insanity. At one time he is noisy,
excitable and inclined to be abusive. After this period has passed he becomes
depressed, morose and despondent. At present Mr. Baldwin is despondent and
looks upon the dark side of everything. He is agitated at times and worried
regarding his future.
A similar statement is made nearly one year later, in June 1919:
June 26 Special Report. He is suffering from maniacal depressive insanity. He
is quite unreliable. Says one thing today, tomorrow another. He has periods of
depression and periods of escalation. He is just recovering from the depressive
stage of his malady.
These two descriptions of Baldwin’s illness now follow an easily
recognizable pattern that neatly captures the cyclical nature of
mania/depression, a pattern that had been difficult to discern seven
years prior, with his first hospitalization. These descriptions are
strikingly different from Hayes Newington’s first Medical Certificate
(reproduced above), which carefully avoided any diagnosis other than
the standardized and vague medico-legal jargon ‘not of sound mind
and judgment’, a catchall diagnosis justified by the accumulation of
specific behavioral descriptions that obscure rather than reveal a
pattern; that Certificate was essentially an accretion of observational
details meant to buttress the hollow nature of the diagnosis. By
contrast, McDowall’s clinical descriptions are entirely devoted to
revealing the pattern of the disease, which seems to satisfyingly mirror
its textbook description. In fact, we know that McDowall was
intimately familiar with the clinical description of the disease from his

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review of a French monograph devoted to this topic, which he had
published in the British Journal of Psychiatry in 1908 (McDowall
1908). Thus we would argue that by 1918 the term ‘manic-depressive’
insanity had become a term of art ensconced or rather, ‒enregistered
in the vocabulary of practicing psychiatrists, and as such, the patterns
that used to be obscured by a thick layer of pathological description
emerge once the stencil of the Kraeplinian categories is applied.
Similar descriptions appear sporadically throughout Baldwin’s
final seven-year hospitalization at Ticehurst. Baldwin is eventually
discharged to the care of a Mrs. Wells of Heathfield Hotel in
November 1925 and leaves Ticehurst for the last time.
3. Discourse analysis of Baldwin’s case notes
We transcribed the entirety of Baldwin’s Ticehurst case notes and
decided to code them based on inductively built categories; in
particular, we discussed code categories and conducted extensive
norming sessions in order to smooth disagreements. In the end we
created a coding scheme for several categories, out of which we have
decided to focus on the most important for our purposes of tracking
Manic-Depressive Insanity. These categories include symptoms of
mania, depression, and lucidity. All categories were coded by T-Unit ‒
a complete independent clause with all of the dependent clauses or
phrases attached.
3.1. Symptoms of mania
This category identifies any T-unit describing a symptom of mania. No
distinction was made between general descriptions of mania symptoms
(e.g. “he is very talkative”) and more specific behavior descriptions
indicating mania (e.g. “he abusively spoke to his attendant this
morning”). Note that grandiosity is a common symptom of mania in

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this patient. This category includes mischief and inappropriate
behavior, such as Baldwin’s extravagant dress and amorous tendencies.
(1) He is undergoing an attack of active recurrent mania. He is excited, very
coarse and abusive. He never ceases talking. (Medical Statement, February
21st, 1916)
3.2. Symptoms of depression
This coding category includes neurotic worry, such as Baldwin’s back-
and-forth fears regarding leaving Ticehurst as well as his anticipating
legal and financial trouble.
(2) Was in a very depressed condition, said he felt to be so but could give no
reason for it. (Medical certificate #1, 30 May, 1913)
This category also includes suicidal thought and/or reported speech/
behavior.
(3) He states that two days ago he swallowed a large quantity of broken glass. He
says he felt impelled to swallow it and could not help himself. (Medical
certificate #2, 30 May, 1913)
3.3. Improvement, or possible lucid interval
This category applies to case notes that describe improved or lucid
behavior. No distinction was made between direct statements of
improvement (“He is improved”) and descriptions of behaviors that
provided evidence of improvement (“This patient is quieting down”).
4. Results

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The results of our coding (Tables 2 and 3, below) reflect the alternating
pattern of symptom reporting in the case notes for example, where‒
few or depression symptoms are reported, manic symptoms are
frequently reported, and vice-versa. There is also a tendency to over-
report manic symptoms by comparison with depression or
improvement symptoms an understandable tendency if we consider‒
that each hospitalization is usually the result of a manic episode during
which the patient is in crisis and psychiatric staff must manage varied
manifestations of mania. We are showing these data in both 1- and 2-
year increments: the 1-year breakdown of data provides a ‘natural’
division while the 2-year breakdown of data reveals a more
pronounced clustering of symptoms on either side of depression or
mania.
Depression Mania Improvement
1911 0 42 11
1912 0 32 10
1913 24 0 32
1914 10 0 12
1915 3 0 7
1916 0 50 14
1917 0 10 2
1918 23 1 1
1919 23 0 0
1920 17 0 6
1921 4 0 5
1922 1 23 7
1923 1 2 2
1924 3 46 6
1925 0 22 1
Totals 109 228 116
Table 2. Frequency of depression, mania, and improvement symptoms as recorded in
Baldwin’s case notes in 1-year increments, 1911-1925.

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Depression Mania Improvement
1911-1912 0 74 21
1913-1914 34 0 44
1915-1916 3 50 21
1917-1918 23 11 3
1919-1920 40 0 6
1921-1922 5 23 12
1923-1924 4 48 8
1925 0 22 1
Totals 109 228 116
Table 3. Frequency of depression, mania, and improvement symptoms as recorded in
Baldwin’s case notes in 2-year increments, 1911-1925.
To get a better sense of the symptom reporting patterns, we have
created charts for each of Baldwin’s hospitalizations, which we
compiled into a single chart to better show the longitudinal aspect of
his disease. Below are graphs documenting the frequency of our three
main categories in Baldwin’s coded case notes across 1- and 2-year
increments.
Figure 1. Coded Symptom Frequency (1-year Increments).
Figure 2. Coded Symptom Frequency (2-year Increments).
Note that these two graphs represent the frequency of case notes
documenting the manic, depressive, and lucid interval symptoms
rather than the intensity of the symptoms of the day-to-day order or
number of symptoms. This distinction is important because the two
graphs confirm that to the physician-writers at Ticehurst the ebb and

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flow of mania and depression can be visually organized in a
predictable, recognizable manner for someone who understands and
accepts the concept of manic depression.
5. Discussion
The charts in Figures 1 and 2 validate the eventual diagnosis and echo
earlier visual representations of the disease that are attempted in the
psychiatric literature (e.g. Paton 1905). Nevertheless, two patterns can
be seen to be salient in this visual representation:
1. The apparent disproportionate reporting of manic episodes
versus depressive or lucid intervals, especially during the first
hospitalization. This asymmetry can possibly be explained by
the certificating physician’s need to foreground the more
sensational, visible aspects of manic behavior necessary for
certification. As the case progresses and the diagnosis becomes
more clear, the manic and depressive symptoms seem to be more
balanced or at least more routine except toward the end of‒
Baldwin’s final hospitalization (which most likely occurred at
the end of a manic cycle). We may also speculate that what we
have been calling the enregisterment of ‘manic depression’ in
psychiatric vocabulary has a ‘normalizing’ effect on the way
psychiatric symptoms are reported in the case notes, by which
we mean that they offer a lens (a ‘terministic screen’ in Burkean
rhetorical parlance) that speeds the process of pattern
recognition in interpreting widely divergent behaviors. Thus
what was once a ‘highly interesting case’ for Newington in 1913
becomes relatively routine for MacDowell in the 1920s.
Consequently, the volume of the observational notes decreases
sharply during the last seven-year hospitalization, in contrast
with the rich details accumulated during the first few
hospitalizations.

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2. The case notes reporting improvement or ‘lucid intervals’
decrease considerably after 1918, the year Colin MacDowell
first officially diagnoses Baldwin. In fact, they are highest in
1913, the year Hayes Newington, the older physician who dies
in 1917, has the prescient insight into Baldwin’s condition.
Hayes Newington had also been opposed to ‘certifying’ Baldwin
as ‘unsound’ at the time, despite his considering him a good
candidate for the diagnosis of manic-depressive insanity, arguing
that this certification would hinder the patient’s recovery. We
may in fact look at this as a stage in the uptake process where
the gravity of manic-depressive insanity may be a concept still in
flux, and recovery is still thought possible. The other possibility,
of course, is that as patients became chronic, the number of lucid
intervals diminished. Conversely, McDowall, operating under a
new nomenclature that officially includes MDI as a diagnosis of
insanity, may be less inclined to report on ‘lucid intervals’,
except on rare occasions. In fact, the sporadic nature of entries in
Baldwin’s case history between 1918 and 1925 (by comparison
with his previous five hospitalizations) suggests that Baldwin
has become a chronic long-term incurable patient, those‒ ‒
Trevor Turner (1989) calls ‘hardy perennials’.
6. Conclusion
We could tentatively interpret these results as a visual representation of
the ‘subjectivity’ of the medical/psychiatric gaze that can only see
what the available linguistic and conceptual framework allows it to
see. To the doctors attending to Baldwin’s case, the circularity or the
longitudinal evolution of the disease becomes visible when a relevant
category comes along to help them interpret it. The concept of
‘maniacal-depressive insanity’ is thus used to definitively tame a
tangled array of symptoms encompassing over time the totality of the
patient’s experience.

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The narrative and extensive nature of the case notes allows for
the flashes of insight into Baldwin’s case, such as Newington’s
realizations; this is possible because the concept of MDI is in the
zeitgeist, so to speak, and it is ready for its uptake from hypothetical
nosology to practical experience. The analysis of this case is, we
believe, the first time researchers using archival data (case
notes/histories) have been able to track the detailed documentation of a
patient’s manic-depressive symptoms over time, thus providing a
snapshot of the enregisterment process that resettled psychiatry’s
foundations in the early 20th century. Indeed, Baldwin’s case reflects
the transition from a medico-legal register to a Kraeplinian register.
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Appendix
List of Baldwin’s hospitalizations at Ticehurst
Hospitalization 1: June 24, 1911 – Nov. 20, 1912
Hospitalization 2: Feb. 15, 1913 – Apr. 10, 1913
Hospitalization 3: Apr. 14, 1913 – June 1, 1913 (as voluntary boarder)
Hospitalization 4: Jun. 1, 1913 – Jan. 21, 1916 (change in status to ‘certified patient’)
Hospitalization 5: Feb. 16, 1916 – Jul. 12, 1918
Hospitalization 6: Jul. 18, 1918 - Nov. 9, 1925