This chapter covers Saint Elizabeths during the tenure of its first superintendent, Charles H. Nichols (1855–1877), including the impact of the Civil War on the composition of the patient population, the general operation of the hospital, and the overall treatment of African American patients. Although blacks were among the soldiers, sailors, and federal prisoners admitted to the hospital in its early years, the majority of African American patients were indigent civilian residents of the District. The Civil War led to emancipation in the District and the influx of contrabands—black refugees and fugitive slaves—into the city, making it difficult for hospital officials to employ a strict residency requirement for admission. The chapter also explores the ways in which racial discrimination characterized the hospital’s therapeutic regime. It further reveals how African American patients and their families sought to shape their own experiences in the hospital.