The first comprehensive view into the conditions of Maryland almshouses came in a groundbreaking 1877 report by Dr. C. William Chancellor, the Secretary of the State Board of Health.  Chancellor personally visited each Maryland almshouse and jail and wrote up a scathing report condemning their condition and administration.  "It is painful to report the shocking condition in which many of the public institutions were found, and it is difficult to conceive that anything worse ever existed in a civilized country".  He described numerous examples of mentally ill patients being held in unnecessary restraints, inadequately fed, and improperly housed.  In regard to all such institutions, Chancellor concluded: "For the insane there is written over the portal of the almshouse as those over the infernal regions, 'Whoever enters here leaves hope behind'".

The responsibility for the regular inspection of almshouses eventually passed to the Maryland State Lunacy Commission.  Founded in 1886, the Lunacy Commission possessed nominal oversight over all the mentally ill held in institutions throughout the state. As part of its charge, the commission secretary made visits to state hospitals, almshouses, asylums and jails every six months and reported his findings to the governor.  As first organized, this body had little power to effect any change.  Public shaming appeared to  be the only tool at hand, and the commission used it in the pages of its annual report.  But few people ever saw the contents of these publications.  The early reports featured no illustrations.

The Lunacy Commission reports, though, often contained very graphic descriptions.  They uniformly decried the use of almshouses for the reception and housing of the insane.  Since most almshouses lacked any form of recreation, employment, or therapy, the mentally impaired, even those not held in some form of physical restraint, whiled away the hours seated on benches or aimlessly roamed the halls and the grounds.  Conditions varied in different county almshouse, but generally speaking the daily administration of most almshouses could be described as loose.  Superintendents, often local farmers appointed through political influence, sometimes changed yearly.  Attendants had no training in the care of the mentally ill, which meant that physical restraints often were used on patients, even though some Maryland medical professionals had disapproved of the practice since the 1870s.  In at least one case improperly applied restraints led to the death of a patient from gangrenous hands.  Sometimes attendants used their fists to subdue the demented or unruly.  It appears that senile elderly were merely locked in cell-like rooms to keep them from wandering away.  Reports speak of the "almshouse diet," a subsistence diet consisting mostly of hominy or oatmeal as the daily fare.

Another term, "almshouse odor," can easily be imagined as being an oppressive presence in a building that lacked indoor plumbing or bathing facilities, and regular, daily care for the incontinent or chronically ill population.  The deceased sometimes lay on their beds for several days before the undertaker made his appearance.  Some almshouse structures dated from the eighteenth century; others, reserved for African Americans, appeared to be nothing more than old, drafty slave quarters. 
 
 

Almost every Lunacy Commission annual report calls for the building of a proper state facility for the African American insane.  A string of commission secretaries recognized that the almshouse housing reserved for people of color almost always was of poorer condition than that for whites, usually "a dilapidated cabin, more or less clean, and always overcrowded."  Speaking of a western Maryland county facility, one secretary thought that "the beasts of the field are taken better care of than the poor negroes."  Race segregated facilities existed in many counties, though for want of funding, certain counties breeched this unwritten law, allowing the races to co-habitate.