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With the death of Thomas Salmon, M.D. in a sailing accident on August 13, 1927, the mentally ill lost one of their most respected and influential advocates of that era. Salmon\u2019s journey from failed family doctor to the upper echelons of American psychiatry reflects both his personal drive and his empathy for those struggling with their mental health. He was also a man defined by paradoxes. Although Salmon wore the uniform of the U.S. Public Health and Marine Hospital Service or the U.S. Army Medical Corps for much of his career, he had an allergy to authority of all kinds. (A 1906 investigation by the Public Health Service into his refusal of a direct order on Ellis Island pronounced Salmon \u201cfar from loyal, obedient or even consistent\u201d (Unrau 1984, <\/em>679).) Later, Salmon would be praised for his superb organization and management of psychiatric services for American soldiers in World War I, yet he was also well-known as one who couldn\u2019t pay his own bills or debts on time.<\/p>\n\n\n\n Early Life<\/strong><\/p>\n\n\n\n Born in 1875 in Troy, New York, Salmon was the son of a family doctor who had immigrated from England. He graduated from Albany Medical College in 1899 and returned home to establish a medical practice. Salmon was a skilled artist whose work appeared in at least one medical textbook (Gordinier 1899). Salmon\u2019s career as a family doctor was short-lived. He refused to advertise in the local newspapers, despite the highly competitive nature of medicine in that era. Although certainly a competent physician, Salmon proved a terrible businessman. When he did bill for his services, he neglected to chase payments. By the time he left his practice, Salmon had uncollected bills of $15,000-$25,000 (Komora 1937, McKown interview).<\/p>\n\n\n\n Seeking a steady income for his growing family, Salmon took a position at Willard State Hospital in New York, a mental institution, where he was hired to investigate\u2014and end\u2014a diphtheria epidemic (Russell and Salmon 1905). Not satisfied with laboratory work, Salmon decided to enter the Public Health and Marine Hospital Service (later shortened to \u201cPublic Health Service\u201d). He may have at first failed the highly competitive exam, which took place in Washington D.C. each year over a three-day span, but Salmon eventually passed and entered Public Health and Marine Hospital Service in 1903, and was assigned to Ellis Island.<\/p>\n\n\n\n Ellis Island<\/strong><\/p>\n\n\n\n While Willard State served as Salmon\u2019s entry into psychiatry, it was at Ellis Island that Salmon became fully immersed in the specialty. Salmon was initially assigned to the immigrant inspection line, where he and other Public Health and Marine Hospital Service physicians did a cursory examination of steerage-class passengers, seeking to identify those with dangerous contagious diseases, mental illness, and \u201cfeeblemindedness.\u201d These immigrants would be sent to Ellis Island Hospital, a facility on its own artificial island that would grow to 650-beds, for treatment and observation. Some of them would be refused entry and returned to their home country on the basis of their condition.<\/p>\n\n\n\n Unsettled by the rough handling of insane immigrants, Salmon pushed for better care. Arriving immigrants, particularly in the early 1900s, suffered from the harsh conditions of steerage, without clean water, decent food, and proper sanitation for the 7-21 day journey to the United States. Sleep-deprived, they arrived at Ellis Island homesick, disoriented, and afraid. Salmon noted that a bath, clean clothes, good food, and rest often eliminated their \u201cinsanity.\u201d<\/p>\n\n\n\n As there were no special wards for these immigrants, Salmon, with his drawing skills, designed one. It would be built after his conflicts with his superior officers, stemming from his unwillingness to work on the inspection line, resulted in his transfer to the port of Boston. With a growing number of foreign-born patients filling its state mental asylums, in 1911 the New York State Commission in Lunacy approached Salmon, whose work at Ellis Island had grown his reputation, to study its immigrant insane, provide statistics, and create a standardized system of reporting admissions and discharges. Granted a leave of absence from the Public Health Service, and offered a substantially higher salary, Salmon got to work. Salmon was among those who pushed for medical examination of immigrants before they departed from their home countries for the United States, so those with mental illness would not be permitted to come to the United States at all.<\/p>\n\n\n\n Mental Hygiene Movement<\/strong><\/p>\n\n\n\n Salmon\u2019s work in New York State attracted the attention of Clifford Beers, founder of the mental hygiene movement. A Yale graduate, Beers was himself a former mental patient and told his story in A Mind that Found Itself: An Autobiography<\/em>, which was published in 1907. Beers exposed that too often the only \u201ctreatment\u201d for the insane were straightjackets and violence on the part of the untrained attendants. Beers established the Connecticut Society for Mental Hygiene, which by the next year was renamed the National Committee for Mental Hygiene (NCMH). The organization lives on today under the name \u201cMental Health America\u201d (\u201cMental Health America: Our History\u201d).<\/p>\n\n\n\n Salmon joined the NCMH, serving as its Medical Director from 1912 to 1922, taking a leave of absence from 1917 to early 1919 to serve in the U.S. Army Medical Corps. With a salary paid by the Rockefeller Foundation, Salmon finally resigned his Public Health Service officer commission at the end of 1914. Salmon\u2019s work at the NCMH exposed conditions in state asylums (\u201cAnnual Meeting of the National Committee for Mental Hygiene\u201d 211). In the 1920s, the NCMH wrote and lobbied for model commitment laws (\u201cMental Health America\u201d), which were passed by the states.<\/p>\n\n\n\n Advocating for \u201cShell-Shocked\u201d Soldiers<\/strong><\/p>\n\n\n\n In the U.S. Army Medical Corps had the daunting task of setting up psychiatric hospitals and recruiting doctors and nurses to work in France. Upon his return in 1919, Salmon pushed for proper care of soldiers suffering from \u201cshell shock,\u201d what is generally known today as post-traumatic stress disorder. When he learned that such victims would be put in hospitals and institutions without proper psychiatric staffing and treatment, he said that \u201c\u2026 you can\u2019t take care of these sick men in facilities like those, just as though they were so many stalls to house so many horses\u201d (Komora 1937, Bryan interview). Salmon became a national figure in the 1920s, giving fiery speeches for the American Legion and testifying before Congress demanding that the country provide for veterans who returned with mental disorders. It put him at odds with the Harding administration and the Public Health Service (which was supposed to care for such men), and alienated the Rockefeller Foundation. But his advocacy helped establish what would eventually become the Veterans Administration.<\/p>\n\n\n\n Practical Psychiatric Treatment<\/strong><\/p>\n\n\n\n After his return to the United States from France, Salmon became active in the American Psychiatric Association. He also developed a lucrative private practice, which didn\u2019t end his lifelong money woes, but did improve his financial standing. Among his patients was Marion Frankfurter, the wife of the future Supreme Court Justice. Marion Frankfurter suffered from bouts of depression throughout her life. She lauded Salmon for the \u201cextraordinary skill and gentleness with which he led me through the dark wood.\u201d Her interviewer, Paul Komora of the NCMH, wrote, \u201cAs Mrs. F. put it, Salmon virtually saved her life\u201d (Komora 1937, interview with Felix and Marion Frankfurter). Salmon turned down $50,000 a year to treat Stanley McCormick, an heir to International Harvester\u2019s family fortune (Komora 1937, Brumley interview). At the time, physicians in private practice earned $5,000 to $10,000 a year (Bendix 2023).<\/p>\n\n\n\n Seeking to improve the teaching of psychiatry as a discipline and interest more capable medical students to enter the field, Salmon joined the faculty of the Columbia University College of Physicians and Surgeons in 1921. Psychiatry was very much a rapidly developing field in the first decades of the Twentieth Century, as doctors sought ways to more effectively treat the mentally ill rather than simply warehousing them in institutions. Lynn Dumenil\u2019s 1995 analysis of the forces that shaped the 1920s, The Modern Temper<\/em>, highlights the work of Sigmund Freud and John B. Watson (146) in its discussion of psychiatry and psychology. Both of these thinkers could be put on the opposite ends of a spectrum. Freudianism, with its emphasis on the unconscious mind, sex, and repressed desires, could be located on one end, while Watson, whose work focused on the study of discernable, measurable behaviors and their manifestation in an individual\u2019s external actions and reactions, could be placed on the other.<\/p>\n\n\n\n Salmon and the mental hygienists are in the middle of this spectrum. Mental hygienists certainly believed in talk therapy (Freud), and they saw the value of identifying behaviors and attempting to understand their relationship to the patient\u2019s environment (Watson). For example, Salmon was called in to treat a boy who was caught tampering with the signal mechanisms of a railroad near his boarding school. Such vandalism could have proved deadly. After spending some time with the child, who was about to be kicked out of his school, Salmon found he displayed an unusual ability in mechanical and electrical work. His \u201cprescription\u201d was to arrange much more time for the boy to study these subjects. In this example there is an attempt to identify the issue and identify a practical solution, rather than delve deeply into a person\u2019s psyche, on the one hand, or reduce them to a simple set of actions\/reactions, on the other.<\/p>\n\n\n\n Expanding Psychiatry<\/strong><\/p>\n\n\n\n This sort of approach was particularly important in the \u201cchild guidance clinics\u201d the NCMH set up in cities (Blanton et al., 1927), as well as the work Salmon helped organized in Sing-Sing prison (\u201cPsychiatric Services for Prisoners\u201d 1916). Though neither he nor the mental hygiene movement are mentioned in Dumenil\u2019s survey, Salmon and other leaders were effective in reducing the stigma of mental illness and pushing for treatment of the insane, rather than imprisoning them in state institutions. They focused on not only ending the abuse and isolation of patients in mental institutions, but sought to end long-term, involuntary incarceration. They pushed for psychiatric treatment in the communities where the mentally ill lived, in an out-patient fashion, before such clinics were widely established. We particularly see the legacy of the mental hygienists in the lessening of the stigma of mental illness as well as the evolution of the principal profession body for psychiatrists, the American Psychiatric Association.<\/p>\n\n\n\n Founded in 1844 as \u201cThe Association of Medical Superintendents of American Institutions for the Insane\u201d and then in 1892 as \u201cThe American Medico-Psychological Association,\u201d the organization finally became \u201cThe American Psychiatric Association\u201d (APA) in 1921. Such name changes signaled the transformation of psychiatry from a discipline concerned with patients in mental institutions to one with broad scope to treat the range of mental disorders (Ozarin and McMillan, \u201cAPA History\u201d). In 1923, Salmon was elected the president of the APA, the first one who had not served in a leadership capacity at a state mental institution. \u201cThe ideal psychiatrist was no longer the institutional superintendent of the [eighteen] eighties, or even the man of the laboratory of the nineties,\u201d wrote Barbara Sicherman (1967, The Quest for Mental Health in America, <\/em>280). Ever progressive, the new psychiatrist, who worked in schools, prisons, and<\/em> hospitals, collaborated with social workers and educated laymen, had become an advocate of \u201cscience with a public mission,\u201d an apt description of Thomas Salmon.<\/p>\n\n\n\n Bibliography<\/strong><\/p>\n\n\n\n \u201cAnnual Meeting of the National Committee for Mental Hygiene.\u201d 1928. Mental Hygiene.<\/em> 12: 211.<\/p>\n\n\n\n Beers, Clifford Whittingham. 1907. A Mind that Found Itself: An Autobiography<\/em>. Doubleday & Company, Inc.<\/p>\n\n\n\n Bendix, Jeffrey. September 28, 2023. \u201cA Century of Primary Care Transformation, Chapter 1: 1923 vs. 2023: A Doctor\u2019s Daily Life.\u201d Medical Economics Journal<\/em>. 100:10.<\/p>\n\n\n\n