As before remarked, the magnitude of an asylum, and the paucity of its medical officers, are matters of much more serious import where recent cases of insanity are under treatment. In a colossal refuge for the insane, a patient may be said to lose his individuality, and to become a member of a machine so put together as to move with precise regularity and invariable routine;--a triumph of skill adapted to show how such unpromising materials as crazy men and women may be drilled into order and guided by rule, but not an apparatus calculated to restore their pristine condition and their independent self-governing existence. In all cases admitting of recovery, or of material amelioration, a gigantic asylum is a gigantic evil, and, figuratively speaking, a manufactory of chronic insanity. The medical attendant, as said before, is so distracted by multitudinous duties, that the sufferer from the acute attack can claim little more attention than his chronic neighbour, except at the sacrifice of other duties. No frequent watching several times a day, and no special interest in the individual case, can be looked for. There is such a thing as a facility in observing and dealing with the phenomena of acute mental disorder, acquired by experience; but it would be well nigh unjust to expect it in a medical officer, in whose field of observation a case of recent attack is the exception, and chronic insanity the rule, among the hundreds around.
The practical result of this state of things is, that the recently attacked patient almost inevitably obtains less attention than he needs from the physician, who, from lack of sufficient personal observation, must trust to the reports of others, to the diligence, skill and fidelity of his attendants, and who, in fine, is compelled to repose work in others' hands which should rightly fall into his own.
This being the case, the character of the attendants for experience, knowledge, tact and honesty acquires importance directly proportionate to the size of asylums, and the degree of inability of the medical superintendents to perform his duties personally. Now, though we need testify to the excellent qualities of some asylum attendants, yet, notwithstanding any admissions of this sort, it is a serious question how far such agents should be employed to supply the defects and omissions of proper medical supervision and treatment. The class of society from which they are usually derived; their common antecedents, as persons unsuccessful or dissatisfied with their previous calling, or otherwise tempted by the higher wages obtainable in asylums, are circumstances not calculated to prepossess the feelings in favour of their employment in that sort of attendance on the insane alluded to. They have no preliminary instruction or training, but have to learn their duties in the exercise of them. Many are their failures, many their faults, and often are they very inefficient, as the records of every asylum testify; yet, on the whole, considering their antecedents, and the nature of the duties imposed upon them, their success is remarkable. However, whatever their character as a body, as individuals they require the direct and ever-active oversight and control of the superintendent. The institution of head-attendants is a great relief to the labour of the latter, but rightly affords him no opportunity to relax his own inspection and watchfulness.