In a large asylum there must be general routine: it can be conducted only by routine; and the attendants are the immediate agents in carrying it out. Their duties necessarily partake largely of a household character; they are engaged in cleaning and polishing, in bed-making and dressing, in fetching and carrying, and in serving meals. But along with these they are entrusted with certain parts of the 'moral treatment' of the patients,--in enforcing the regulations as to exercise, employment, amusement, the distribution of meals, and the general cleanliness and order both of the wards and their inmates; and in the exercise of these functions acquire much knowledge respecting the character and habits of those under their care. Yet withal, they are not fit and efficient persons to have medical duties delegated to them. They are not qualified to observe and record the symptoms of disease, to note its changes, nor, except under close surveillance, to apply remedies externally or internally.
Such is the onset or the serious march of bodily sickness not unfrequently, that even the experienced medical observer is prone to overlook it. This is true where disease attacks those sound in mind, and able to express their sufferings, and to lend the aid of their intelligence towards the discovery of the nature and seat of their malady; but the danger of oversight is increased tenfold when the insane are the subjects of bodily lesion. Where the mind is enfeebled and sensibility blunted, and where melancholy broods heavily over its victim, disease is to be discovered only by a watchful and experienced practitioner of medicine; for the unfortunate patient will make no complaint, and the fatal malady may evince itself to the ordinary uninstructed observer by no sufficient symptom to awaken attention; and even where the mind is not imbecile, nor weighed down by its fears and profound apathy, yet the features of its disorder will interfere, in most instances, with the appreciation and interpretation of the symptoms which may reach the knowledge of those about the sufferer, and thereby mask the disease from the non-professional looker-on, and render its diagnosis even difficult to the medical examiner.