Historians recognize Adolf Meyer (1866-1950), first psychiatrist-in-chief at Johns Hopkins Hospital, as one of the principal architects of clinical psychiatry in the United States. This wholesale influence on the fledgling discipline had much to do with the authority he wielded as a Hopkins chief, but an important question remains: why was Meyer the obvious candidate to establish a department of psychiatry at the nation's foremost institution for medical research and teaching? Taking examples from Meyer's employment in three large American asylums before his appointment to Johns Hopkins in 1908, this article explores how he transformed an improvised set of practices into a clinical system for psychiatry that he implemented on a widespread scale, something that garnered him a reputation as a modernizer of outdated asylums and pegged him, in the minds of Hopkins authorities, as a psychiatric exemplar of commitment to pathological research and clinical teaching.