Madness

How do you tell the truth about a place built to help and to harm? In Madness, Antonia Hylton argues that Crownsville—the Maryland Hospital for the Negro Insane—was never a neutral medical site. It was a racially engineered solution to social anxieties about Black freedom that fused psychiatry with segregation, labor extraction, and carceral control. Hylton contends that to understand Crownsville’s history—and the afterlives of that history in today’s mental-health and criminal-legal systems—you must see how race shaped every layer of institutional life: who was admitted, how they were treated, what work they did, how they were remembered, and why the record of their lives often disappeared.

In these pages, you trace a century-long arc. You start with a Jim Crow origin story: a state builds an asylum for Black Marylanders on cheap, rural land and then uses the people inside to construct and maintain the campus. You move through midcentury, when therapeutic language justifies coercive treatments, and “industrial therapy” becomes a euphemism for unpaid labor. You see racial terror and legal power collide with psychiatry—lynching on the Eastern Shore, judges committing civil-rights protesters to Crownsville—and recognize a broader ecosystem of control.

What you learn about institutions

You learn that buildings and budgets tell a story. Crownsville prioritized beds and farms over therapy rooms and training, with appalling crowding and few clinicians. Public outcry (like Howard Norton’s 1949 “Maryland’s Shame”) prompted investments that added more beds rather than more care. Underfunding wasn’t an accident; it was policy. Leaders like Kenneth B. Jones bluntly asked why Crownsville’s per-patient spending lagged white hospitals by half. The answer was segregation’s arithmetic: separate meant lesser.

You also meet people who complicate the narrative. Superintendents such as Jacob Morgenstern pushed desegregation and hired Black professionals; psychologists like Vernon Sparks created training pipelines. Black nurses and aides—Gertrude Belt, Faye Belt, Delores Hawkins—built humane spaces inside an inhumane design. Their daily improvisations, from moving patients out of “the cage” to talking someone down from a roof, are the book’s moral center.

How power shaped treatment

Midcentury psychiatry was both innovative and brutal. At Crownsville, hydrotherapy, insulin comas, Metrazol, electroshock, and lobotomy were practiced under conditions of limited consent. Elsie Lacks—Henrietta Lacks’s daughter—almost certainly underwent pneumoencephalography, a procedure that left scars and suffering, before dying at the hospital in 1955. Staff memories suggest that shock sometimes functioned as discipline, not cure, and Black aides were conscripted as enforcers within a hierarchy they did not control. Research partnerships dangled prestige while masking unequal risk.

Race also shaped diagnosis and detention. During the Civil Rights era, schizophrenia shifted culturally from a diagnosis of withdrawal to one of hostility (as Jonathan Metzl documents). Judges leveraged hospitals for containment, exemplified by the Elkton Three: civil-rights activists Juanita and Wally Nelson and Eroseanna “Rose,” whose sit-in at a Route 40 diner ended in a judge’s commitment order to Crownsville. Superintendent Charles Ward found them sane; the point had already been made—psychiatry could be a tool to police dissent.

Archives, grief, and afterlives

Hylton writes amid archival absence. Patient master cards are sparse; detailed files vanished—destroyed, lost, or contaminated. That silence forces you toward oral history: Janice Hayes-Williams reconstructs cemeteries and identities; volunteers like Sonia King and archivists like Paul Lurz preserve names, autopsies, and photographs; former staff offer ethically complicated testimony. The cemetery itself—numbered graves, unclaimed bodies sent to medical schools—makes erasure tangible and demands ritual repair.

Deinstitutionalization promised better alternatives and delivered far less. Medications and policy reforms shuttered asylums without building robust community care. Crownsville closed in 2004; prisons swelled as hospitals emptied. Conditional release regimes demanded stability many did not have, turning freedom into supervision. The book’s final movement insists that memory is part of justice: Janice’s Say My Name ceremony, county-level preservation, and proposed memorials counter a century of silence.

Core claim

Crownsville shows you how a society medicalizes difference, racializes diagnosis, extracts labor as “therapy,” and then buries the evidence—unless communities insist on remembrance and repair.

The book leaves you with a usable past. If you work in policy, it warns against closing institutions without funding care. If you practice medicine, it reminds you that consent, coercion, and culture are inseparable. If you’re a descendant or neighbor, it invites you to demand names, records, and rituals that dignify the dead. Madness is institutional history braided with intimacy—Pauli Murray’s father William H. Murray, the author’s family encounters with police and psychosis, the soft-spoken heroism of Black staff—that turns abstraction into a call to act. (Note: Read alongside Rebecca Skloot’s The Immortal Life of Henrietta Lacks or Anne E. Parsons’s From Asylum to Prison for complementary perspectives.)

Hylton shows you Crownsville’s founding as a Jim Crow policy choice. In 1910, Maryland’s legislature created the Hospital for the Negro Insane to remove Black people deemed “insane” from public view and almshouses, and to contain their presence far from Baltimore. Dr. Robert P. Winterode arrived in 1911 with a blueprint that fused economy with racial control: patients would build and run the institution that confined them. The first arrivals felled trees, mixed concrete, made bricks, and slept in curing sheds—labor framed as “industrial therapy.”

This origin set the terms. Spatial removal to a 1,500-acre campus made oversight scarce. A plantation-style economy emerged: tobacco fields, basketry and rug shops, and a vast farm operation that by 1960 reached 700 acres. Administrators celebrated yields and self-sufficiency. The state cut costs by converting patients into an unpaid labor force; wages, when offered, hovered around fifty cents a day and often recirculated to offset institutional expenses. The Lunacy Commission reported productivity numbers as if they were clinical metrics.

Therapy or exploitation?

Work can heal, but here its logic trapped people. There was no apprenticeship-to-employment pipeline; discharge often depended on institutional need as much as clinical recovery. Dr. J.E.T. Camper alleged in 1949 that Crownsville retained patients who could have been released and sent them to local businesses as “peonage,” especially during WWII labor shortages. The case of William H. Murray—a Howard-educated principal and father of Pauli Murray—makes the paradox intimate: praised for weaving three or four rugs a day sold for $3 each, he died after an attendant’s assault, and his family’s worker’s compensation claim was denied because he wasn’t considered an employee.

Architecture mirrored purpose. Expansion added beds more than treatment space; inspectors found overcrowded wards, filthy floors, and makeshift plumbing. In 1949 Crownsville offered roughly 1.5 square feet of therapy space per patient, compared with 6.3 at white hospitals. The hospital’s physical plant enforced custodial warehousing over individualized care. When the Baltimore Sun’s Howard Norton published “Maryland’s Shame,” outrage yielded money that prioritized capacity, not dignity.

A racialized budget

Kenneth B. Jones, head of the Mental Hygiene Board, asked why Crownsville’s per-patient cost lagged white institutions by fifty percent. The answer was segregation’s ledger: Black institutions received less because they served Black people. Hiring shortages compounded the problem; white professionals often refused to work at an all-Black hospital, leaving too few doctors (as low as one for every 225 patients). Overcrowding and scarcity normalized seclusion cells and restraints—the “cage” for women—turning containment into default care.

Key idea

At Crownsville, “therapy” often meant labor that sustained the institution. Design choices—rural isolation, farm-centric planning, cramped wards—embedded exploitation into daily life.

You should read this as part of a broader Southern logic that assigned Black bodies to institutions rather than services (compare to segregated schools and hospitals across Jim Crow). Crownsville was a self-perpetuating machine: it used those it confined to grow itself, and it grew in ways that served confinement. Patients entered from jails or streets; many never returned home. When you follow the money and the floor plans, you see a policy choice masquerading as medical care.

If you are designing healthcare today, the lesson is practical: resourcing and space signal values. Invest in therapeutic rooms, staffing, and community pathways—or you will default to custody and production. Without accountability, “industrial therapy” becomes another name for unpaid, involuntary work that lengthens stays instead of shortening them. (Note: Industrial therapy existed nationwide, but Crownsville’s racialized labor economy amplified its coercion and erased its rehabilitative promise.)

Midcentury psychiatry at Crownsville sits at an uncomfortable crossroads: innovation without consent, treatment blurred with punishment, and research prestige over patient power. You encounter hydrotherapy (hours or days in hot or icy water under sheeting), insulin coma therapy, Metrazol-induced convulsions, electroconvulsive therapy (ECT), and occasional lobotomies performed off-site. These practices existed nationally, but Crownsville’s underfunding and segregated population made coercion more likely and safeguards weaker.

Elsie Lacks is the book’s unflinching example. Admitted as a child with cerebral palsy and epilepsy, Elsie almost certainly underwent pneumoencephalography—drilling the skull and replacing spinal fluid with air so doctors could X-ray brain structures. The procedure was painful and risky, with side effects like chronic vomiting and seizures. She died at Crownsville in 1955. Autopsy photos and scars galvanized Deborah Lacks and Rebecca Skloot decades later (see The Immortal Life of Henrietta Lacks), and Hylton situates Elsie in a larger pattern: Black patients with little family leverage disproportionately bore the burdens of experimental “progress.”

Consent and power

Crownsville pursued ties to universities and accreditation. Specialty departments and studies promised status and resources. But those arrangements came with ethical gaps. Records of research often disappeared, were never archived, or were sealed. Family consent was inconsistent; patients’ ability to refuse was minimal in a context where seclusion and restraint normalized compliance. Former aide Barbara Shank recalls being part of shock teams, believing she was helping while later reckoning with moral injury. The line between therapy and control blurred when ECT functioned as consequence for noncompliance.

Staff—frequently Black women—were trapped in a double bind. They needed the job and believed in care, yet they were ordered to restrain bodies and deliver treatments in overcrowded wards with too few clinicians. This moral friction accumulates across a career. Testimony from Gertrude Belt and Faye Belt shows how compassion often required rule-bending: moving patients out of “the cage,” watching through the night, or sneaking extra recreation time when official programming was scarce.

Built environment, clinical choices

Poor design increased reliance on coercion. With 1.5 square feet of therapy space per patient and one doctor per 225 patients in 1949, seclusion became triage. Overcrowding amplified agitation; understaffing removed alternatives; “industrial therapy” kept bodies working rather than healing. Even when the state invested after public scandal, it purchased more beds—not trauma-informed spaces, not training centers, not pay for enough licensed staff to reduce force.

Key idea

Treatment cannot be disentangled from the conditions in which it is delivered. Under segregation and scarcity, “care” can reproduce domination even when individual clinicians mean well.

If you practice or design mental-health systems, the implications are immediate. Build consent into workflow; measure coercion and reduce it; separate clinical rewards from research quotas; and ensure patients have independent advocates. Staffing ratios, space design, and funding formulas are ethical instruments, not merely operational details. Without them, therapies that could help become blunt tools for order.

Finally, remember the archive. Missing research logs and shredded files are not neutral accidents; they erase evidence needed for accountability and family truth. Hylton’s reliance on oral histories—Sonia King’s patient-centered stories, Paul Lurz’s rescued autopsy records—becomes a methodological answer to institutional silence. (Note: The arc parallels national reevaluations of ECT, insulin coma, and lobotomy in the 1960s–70s; Crownsville’s story shows how that reevaluation lands hardest on those with least power.)

You can’t grasp Crownsville without the wider terrain of racial terror and legal power. On Maryland’s Eastern Shore, lynching shaped the horizon of possibility for anyone labeled different. Matthew Williams, described by neighbors as cognitively impaired, was dragged from a hospital in Salisbury, mutilated, burned, and desecrated. George Armwood, called “feeble,” was abducted from jail in Princess Anne, beaten, hanged, and burned. Grand juries refused to indict local participants. These were not isolated acts; they were public spectacles that taught communities how easily Black lives could be controlled or erased.

That terror bled into psychiatric pathways. Families, fearing police or mobs, often hid illness as long as possible. When crises erupted, choices narrowed: jail, Crownsville, or violence. County officials—anxious or complicit—used psychiatric commitment as another control lever. In this ecosystem, diagnosis became a social weapon as much as a clinical tool.

The Elkton Three

Civil-rights activists Juanita Nelson, Wallace “Wally” Nelson, and Eroseanna “Rose” staged a sit-in at a Route 40 diner. They refused cooperation and fasted in jail. Judge Rollins ordered them committed to Crownsville. Superintendent Charles Ward examined them and found them sane, but the damage was done: the state wielded psychiatric power to delegitimize protest. Black newspapers like the Baltimore Afro-American named the tactic immediately; mainstream media infantilized the protesters. Commitment became a disciplinary message to would-be dissidents.

Simultaneously, diagnostic rhetoric shifted. As Jonathan Metzl documents, schizophrenia’s cultural image morphed during the Civil Rights era from passive withdrawal to hostile aggression, especially for Black men. Clinicians’ notes at institutions like Ionia recoded anger at injustice as pathology. Meta-analyses show Black Americans are roughly 2.4 times more likely to receive schizophrenia diagnoses than white Americans, with profound implications for detention and drug regimens.

Law, medicine, and control

Emergency commitments, judicial referrals, and police transports turned hospitals into holding tanks. Courts used asylums to manage defendants, and clinicians found themselves gatekeeping freedom without adequate safeguards. At Crownsville, this translated into an institutional identity perched between care and custody—a precursor to later “forensic” expansions and to the jail-as-psychiatric-shelter phenomenon.

Key idea

When protest or nonconformity is pathologized, diagnosis becomes a political act. Crownsville shows how quickly the language of care can mask the practice of control.

If you work at the intersection of health and justice, this chapter is a caution: build firewalls. Ensure independent clinical review for court-ordered evaluations; collect data on racial disparities in diagnosis and length of stay; and adopt standards that prevent hospitals from becoming de facto jails. Train clinicians to differentiate threat from dissent and to contextualize behavior in histories of oppression. Without those guardrails, emergency psychiatry will reproduce the dynamics of the street and the courtroom.

For families, the lesson is equally urgent. Know your rights in emergency commitment; document behavior and triggers; seek advocates early. Crownsville’s history explains contemporary mistrust in Black communities and reminds you that skepticism toward institutions is not paranoia; it’s a learned response to real patterns of harm.

Desegregation at Crownsville was both a breakthrough and a burden. Refugee-turned-superintendent Jacob Morgenstern pushed to hire Black professionals and open training pipelines. Psychologist Vernon Sparks—Maryland’s first Black licensed psychologist—became a quiet architect of reform, placing HBCU graduates in internships and centering patient dignity. Their work rippled through daily life: the cafeteria desegregated only when Morgenstern deliberately sat a white assistant with Sparks on day one, a small gesture that revealed how much courage ordinary integration required.

Black staff like Gwendolyn Lee, Gertrude Belt, and later Dr. George McKenzie Phillips shouldered an emotional load that white colleagues often ignored. They faced open hostility, rapid white staff departures, and administrators who floated bringing in white patients to preserve professional cachet. Even as they gained titles and paychecks, they were tasked with humanizing wards, soothing families, and absorbing racial slights—an unpaid, uncounted labor of care.

Caregivers in a compromised system

The book is rich with acts of everyday heroism. Teenager-turned-nurse Faye Belt chased down runaways, then grew into a protector who moved patients quietly out of danger. Delores Hawkins climbed onto roofs to talk people down, used negotiation over force, and taught colleagues to listen first. Joe Lee carved out recreation—like the Roy Campanella space—that offered joy and social connection. These interventions didn’t fix structural deficits, but they stitched dignity into daily care.

Yet the structural contradictions remained. Underfunding persisted; therapy space stayed scarce; staffing ratios rarely met need. Integration exposed Black professionals to institutional violence—the moral injury of enforcing rules they opposed and working in buildings designed for custody. Many rose economically—Bill and Estella Jones leveraged aide and lab roles into stability and pensions—but at a psychic cost that surfaces in retiree testimonies decades later.

Limits of reform without resources

Morgenstern and Sparks could change culture and build pipelines, but they could not rewrite the budget. Training programs blossomed, yet the hospital’s per-patient spending lagged peers, and capital plans favored beds. Administrators asked for nursing schools and clinical classrooms; politicians delivered dormitories. The result was a fragile progress: a more diverse, empathetic workforce operating within an architecture of scarcity.

Key idea

Integration opens doors but cannot, by itself, dismantle structures built for segregation. Without money, space, and authority, representation becomes repair work done on borrowed time.

If you lead institutions today, borrow the best of this history: pair diversity with power—budgets, hiring lines, and facility redesign. Create clinical ladders for aides, compensate emotional labor, and protect dissent when staff challenge coercive practices. And remember the cafeteria lesson: policy statements matter less than the daily rituals that dignify colleagues in public view.

For communities, the takeaway is to celebrate and sustain the people doing quiet, reparative work inside damaged systems. Their stories—like Sparks’s first lunch, or Faye’s nighttime rounds—are blueprints for how culture changes before statutes catch up. (Note: This mirrors findings in nursing history and Black hospital studies that show how Black women’s care work scaffolded patient survival in segregated facilities.)

Hylton writes into an archive with holes. Maryland destroyed, lost, or allowed Crownsville records to deteriorate; asbestos contamination and alleged shredding further thinned the files. Patient master cards reduce lives to a name, signature, and curt diagnosis. The bureaucratic silence is not just a research problem; it’s a moral one. Without records, families cannot know what happened; victims cannot prove abuse; cemeteries cannot be mapped precisely.

Oral history becomes both method and justice. Janice Hayes-Williams, a local historian, reconstructed the Crownsville cemetery: she combed archives, used cadaver-detection dogs, and linked numbers to names. Her work revealed more than 1,700 burials and roughly 600 unclaimed bodies sent to medical schools. Volunteers like Sonia King and archivists like Paul Lurz preserved photographs and autopsy logs, rescuing fragments the state failed to keep. A single recollection—Mr. Bell stepping outside after years indoors and saying, “I’ll be goddamned, there’s the sky”—reorients you to what care means.

Ritual as reparation

Janice founded the Say My Name ceremony, where people gather to read the dead aloud and lay petals on ground once marked only by numbers. That ritual counters institutional erasure with communal presence. When state officials eyed the campus for sale, Janice rallied lawmakers like Delegate Sandy Rosenberg to preserve the cemetery and invest in memorialization; the county committed initial funds toward a park and museum. Memory becomes infrastructure—money, land-use plans, and annual rites.

Deinstitutionalization’s aftermath sits beside this work. Policy promised community care—JFK’s Community Mental Health Act, Medicaid incentives—but funding fell short. A GAO-style review found only 8 of 47 tracked Crownsville discharges made it to recommended clinics. Conditional release mimicked parole with high revocation rates. As hospital beds emptied (e.g., state hospital declines from the 1960s to 1980s), Maryland’s prison population rose from 7,731 in 1979 to 24,186 by 2003. The book resists simplistic causation yet insists on correlation: the United States traded asylum custody for carceral custody without building the community scaffold in between.

Using the past

For policymakers, Crownsville offers a checklist: do not shutter facilities without funding housing, transportation, clinics, and peer support; measure warm handoffs, not just discharge dates; treat conditional release as care coordination, not surveillance. For archivists and journalists, it argues for independent preservation, consent protocols, and partnerships with families and community historians. For descendants, it models how to reclaim names and demand land-use decisions that honor the dead.

Key idea

Memory work—naming, archiving, ritual—does more than mourn; it redistributes power by restoring evidence, shaping budgets, and reframing public space.

Hylton closes the loop with intimacy. The Murray family’s grief over William H. Murray’s death shadows Pauli Murray’s fear of “going mad” and her legal activism. The author’s own family confronts psychosis in a park and the danger of calling police. Those stories place you in the present tense of Crownsville’s afterlives: stigma, under-resourced crisis response, and the thin line between help and harm. (Note: Pair with Anne E. Parsons’s work on deinstitutionalization-to-prison pipelines for national context.)