Among the most important functions of a clinic are instruction and research. Each assistant in the Munich clinic carries on some chosen line of study. In order that he may have better facilities for becoming acquainted with the literature on the subject and finishing his selected work, he is given, besides his annual month’s leave, two months of each year for this purpose. Frequent evenings are set apart for discussions of original work carried on in the clinic and elsewhere. Besides this, numerous short courses in special subjects are provided, so that it is possible to enter the clinic for instruction in matters requiring a special knowledge of delicate technique and diagnosis.

Of very special importance in the Munich clinic is the course for qualified medical men. In 1907 this was attended by sixty men, of whom one third were foreigners. What can we, in Great Britain, show in comparison with this? Our physical, chemical, physiological, and pathological laboratories attract distinguished foreigners from the universities of other countries, though twenty would be a number on which even our most celebrated laboratories would pride themselves. But how many foreigners come to us to study insanity? Very few indeed, and the reason is not far to seek.

In the Munich clinic, again, we find well equipped rooms for clinical examination, for the deeper investigation of mental life by experimental psychology, for the study of morbid anatomy and pathology and for the finer examination of the blood and other fluids of the body. Furthermore, these laboratories are not only spacious and well-equipped, but are occupied by busy, keen and skilled workers. Testimony to their activity is afforded in abundance by their frequent publications.

We submit, then, that the clinic system is a decided advance in the treatment of mental disorder which other countries have adopted while for years we have stood by with folded hands.[89] From the humanitarian and the scientific point of view there is everything to be said in favour of the clinic. The practical Englishman will, however, ask “What about the financial aspect? Are not these institutions, with their heavy proportion of doctors and nurses to patients, prohibitively expensive?”

The answer to this question is that certainly the clinic is relatively more expensive than the asylum. But since the function of the clinic is to save as many patients as possible from entering the asylum, it is obvious that its expense must be judged from a special standpoint. The maintenance of a repair shop is always comparatively costly, whether the material to be mended be human or not. The cost per day of repairing a motor car is usually distinctly higher than the daily charge for garaging it in its broken-down state. Yet we gladly pay the higher charge for the simple reasons that a motor car in its garage is of no use to us, and that the daily charge for housing the car would amount to a colossal figure if paid for many years. Cannot we apply the same reasoning to the case of the mentally disordered human being? This is to take the very lowest view of the value of the individual to the community. Yet it would seem that the British public, so far, has been impervious even to this financial consideration.

But, it may still be asked, cannot the doctors in the asylums carry out the work suggested? The answer to this is, that apart from the undesirability of allowing a patient suffering from a mild mental disorder to be associated with an institution housing the definitely insane, it is a physical impossibility for the asylum doctors to do this work so long as the present proportion of doctors to patients remains unchanged. How many members of the British public realise the fact that it is quite usual for an asylum doctor to be in charge of at least 400 patients, and that this number sometimes rises to 600? When it is remembered that insane patients are even more prone than the average person to suffer from physical ailments, and that their mental disorders are infinitely complicated by the delay incurred before they come under medical care, it becomes clear that the doctor who would succeed in treating such patients individually would require titanic energy and the addition of at least twenty-four more hours to each of his working days. We cannot therefore compare the staff of a clinic with that of a British asylum, for the staff of the latter is lamentably and obviously too small.

Regarding the financial aspect of the question we may quote again from Dr. Rows’ article:—

“... we shall no doubt be met with the objection that the provision of such institutions will involve the expenditure of such an immense sum of money. I believe we spend in Great Britain about £3,000,000 a year on those suffering from various forms of mental affliction. That, certainly, is an immense sum to spend while getting so little in return. A large proportion of this money is spent in housing, feeding, clothing, and taking care of the 97,000 inmates of the county and borough asylums of England and Wales. We learn from the commissioners’ report, published in 1910, that 20,000 patients were admitted into these asylums during the previous year, and of these, over 30 per cent. were discharged after a longer or shorter detention. Now it may safely be said that very few of these 20,000 fresh admissions did obtain, or could have obtained, any advice for their mental illness at the hands of anyone who had had experience of mental disorders, before they reached the stage when certification and seclusion in an asylum became necessary. When we visited Giessen we were informed by Professor Sommer that in the province of Hesse, by reason of suitable treatment during the early stages of mental illness they had been enabled to postpone for some years the erection of a new asylum in the province. Is it not therefore fair to assume that, if facilities were provided whereby expert advice and treatment in a well-organised psychiatric clinic could be obtained by those threatened with a mental breakdown, we should save enough of the £3,000,000 to justify the expenditure involved in the establishment of such clinics? Further benefits would be derived from them in that we should be able to avoid the breaking-up of the home, which now, in so many instances, follows the removal of the bread-winner of the family to an asylum and his long detention there.”

And

“... it may be suggested that we should attempt to demonstrate the possibility of saving money in order to carry the public with us in the matter. I do not think that is necessary. The value of treatment of the early stages of mental disorder cannot be expressed in pounds, shillings and pence. Moreover, I submit that our duty as medical men is to guarantee the satisfactory treatment of the patient, and we have no right to allow our action to be dominated by monetary considerations. I feel sure that the more this question is placed before the public in an intelligent manner, the more we insist upon the necessity for early treatment and for scientific knowledge as a basis of any treatment, the less will the public grumble about expense. We have ourselves to thank if the public refers so constantly to money matters. Do we ever encourage the public to regard the question from any other point of view? Do we point out that insanity is a product of civilisation? Do we encourage people to regard insanity as an illness for which something can be done and which should be treated with intelligent and humane consideration? Do we not rather say with the public, “Lock him up, put him where he can neither harm himself nor his neighbour?” Do we not talk of sterilising the unfortunate sufferers and preventing marriage and procreation before we have made an honest effort to investigate what insanity really is, what is the mechanism of its production, and how we can teach those so afflicted to help themselves? How then can we expect the public to do anything but grumble at the expense? The public has not objected to spend money in other branches of medicine when the necessity has been demonstrated, and there is no reason, if the members of the lunacy service in this country will develop confidence in themselves, why they should not be able to instil confidence into those outside the profession.”