Among the Rich and Powerful

In 1911, Salmon moved back to New York City to take on a role as Chairman of the State Board of Alienists. In this capacity, he helped advise New York State on matters relating to immigration and psychiatric hospitals, although he would not remain in this position for long. He had been in correspondence with Clifford Beers, who invited him to take on a role as Medical Director of the NCMH in 1912. Salmon accepted, eager for a chance to address chronic underfunding and inefficiency in public health facilities. During this time, Salmon was technically on leave of absence from the Public Health Service. He would eventually resign from the Public Health Service at the end of 1914 (1). 

Salmon’s primary value for Beers was his ability to lend medical credence to the organization which would increase its ability to secure funds from civil society and support from the medical establishment. 

This gamble would pay off. Salmon was instrumental in convincing the Rockefeller Foundation to fund his salary for 1914 and 1915, ensuring that the NCMH’s budget could be devoted to research, outreach, and promotion. Salmon’s negotiations with the Rockefeller Foundation would form the basis of a years-long partnership, which would see the Foundation fund critical aspects of the NCMH’s survey program from 1913 to 1917 (2). 

Salmon cultivated a network of Progressive Era reformers, all of whom were engaged in the newly emerging practice of “social work”. Social work, in the words of Sam Harrell, “applied to a vast array of activities, including organized and systematic help (e.g., charity organization societies), community organizing (e.g., settlement houses), overt correctional work (e.g., workhouses, training schools), and medical intervention (e.g., asylums, hospitals)” (3) The New York City social work ecosystem was particularly rich, with organizations like the Charity Organization Society of New York City (4) and publications like The Survey offering Salmon a ready-made audience for his program of hospital reform. His letters to Caroline B. Alexander, a New Jersey social reformer, exemplify this dynamic. 

Alexander’s family was prominent in Hoboken society. Her grandfather, Colonel John Stevens III, had initially purchased the land that would become Hoboken, and her parents, Edwin and Marsha Stevens, established the Stevens Institute of Technology through the donation of some of the family’s land. A deeply committed social worker, Alexander held a variety of positions throughout her career. In her later life, she became a strong advocate for prison reform, arguing for the creation of separate women’s prisons, probation, and the creation of juvenile courts, to the extent that President Herbert Hoover appointed her the Commissioner of International Prison Commission in 1929. At one point, she was the manager of the New Jersey State Institution for Feeble-Minded Girls and Women in Vineland and manager of the New Jersey State Village for Epileptics (5). It is possibly through this position, and a shared interest in psychiatry, that Salmon and Alexander connected.

Salmon and Alexander met in late 1913 and were in contact through 1914. Salmon approached Alexander for her support, connections, and advice to conduct a study of the poor administration of Ellis Island, especially as it related to federal quarantine practices and the treatment of contagious diseases at ports of entry, a popular topic of the moment. 

Salmon’s most extensive letter to Alexander was written on December 12, 1913, and discusses mismanagement at Ellis Island. Salmon explained how the Public Health Service had the capacity to devote more resources to Ellis Island. As it stood, the standard of care for immigrants was low. Salmon discussed a case in which a detainee drowned after being released by hospital staff into custody of immigration officers (6). Due to administrative negligence, officers did not bother to ensure that the detainee actually boarded a deportation ship. Salmon also lambasted immigration staff for keeping detainees holed up in inadequate detention facilities: 

“At Ellis Island I have heard it said again and again, sometimes by those high in authority, that conditions were ‘as good as they are in the steerage of an immigrant ship’, as if that met the requirements.” (7)

His solutions were to extend the responsibilities of hospital staff beyond hospital premises to encompass the whole of Ellis Island, and to appoint a Commissioner of Immigration trained in social work. Salmon asked that Alexander contribute to an interdisciplinary study of conditions on Ellis Island, including “a physician, a nurse and housing expert”. (8)

Salmon, in this context, adopted a very different approach and mindset when compared to his professional literature on immigration. He identified the human cost of immigration mismanagement in more concrete terms – death, for one. His arguments are not financial at all, and no mention is made of the great cost of the “alien insane” or of the necessity of excluding immigrants to increase efficiency at Ellis Island. This correspondence shows how Salmon could tailor his rhetoric for different audiences. In doing so, the differences between psychiatry and social work are thrown into relief. Professional psychiatry, seemingly, called for Salmon to make emotionless, rational arguments about cost-saving and administrative inefficiency, while social work called on Salmon to make human-centered arguments about malpractice. The tension between these two would contribute to Salmon’s arguments with other psychiatrists and his frustration with inefficient government institutions. In both forms of writing, however, Salmon remained committed to seeking solutions in government through devoting more funds to preexisting institutions.

Much of Salmon’s work at the NCMH involved carrying out surveys of hospital facilities across the US. These surveys involved describing the physical conditions and care practices of psychiatric care facilities. The most influential of these would be an investigation into a rural Texas asylum, "The Insane in a County Poor Farm" in 1917. 

These surveys advanced Salmon’s reputation and the status of the NCMH. The Rockefeller Foundation remarked in their Annual Report for 1915 that, “it has been particularly gratifying, therefore, to see how quickly the advantages to be gained from a critical but constructive study of this problem [psychiatric hospital conditions] by impartial and expert psychiatrists have been recognized and how eagerly such surveys are being sought.” (9)

Just like Salmon’s writings on immigration, and his initial “The Relation of Mild Types of Diphtheria to the Public Health” (1903), these surveys relied on the veracity and persuasiveness of statistics to make their arguments. Statistics, collected according to practices described by industry manuals, provided a scientific and empirical method of analysis. Salmon himself, in fact, played a role in this process. As a member of the American Medico-Psychological Association’s Committee on Statistics, he contributed to the AMPA’s Statistical Manual for the Use of Institutions for the Insane (1918) (10). Statistics strengthened psychiatrists’ claims to scientific rigor, legitimizing psychiatry as a professional, replicable, and standards-based science. In presenting surveys which appeared scientifically sound, the NCMH could present itself as a reputable authority on psychiatric care in the United States. As with Salmon’s career up to this point, statistics cemented his reputation as an epidemiologist and reformer.  

Salmon’s writings on immigration from 1912 to 1914 must be taken in the context of his employment at the State Board of Alienists and the NCMH. Immigration reform and psychiatric reform were two parts of the same project, mobilizing psychiatry’s diagnostic power to advocate for a transformative platform of public health reform. The same principles were active in Salmon’s advocacy for both: confidence in the power of administrative systems to resolve patients’ issues, and a faith in the capacity of psychiatry to tackle social issues. 

Salmon’s statistical and administrative capacities would bring him to the attention of the US army. As it geared up for entry into WWI, Salmon would take on the most important position of his career: psychiatrist to the American Expeditionary Force.