Race structured the everyday labour of caregivers and the treatment of free and enslaved patients in Virginia's asylums from the late eighteenth century through the antebellum period and in the aftermath of the American Civil War. Wendy Gonaver examines how racist attitudes shaped the lives of enslaved healthcare workers, clinicians and both white and black patients at Eastern Lunatic Asylum, established in Williamsburg in 1773, and later at Central Lunatic Asylum, established near Richmond in the postbellum era. Gonaver shows how patterns of labour from plantation slavery influenced Eastern Lunatic Asylum, especially the practice of enslavers hiring out enslaved people. Slavery and slaveholders’ ideas engendered the pathologization of religion and political beliefs as determinants of health or medical risks, especially the perceived dangers of Afro-Christianity and abolitionism. Gonaver's research involved reading and interpreting the records of Eastern Lunatic Asylum's library, including the institution's annual reports, patient notebooks, correspondence and patient registers. Gonaver sifted through the extensive professional correspondence of the asylum's superintendent, John M. Galt, appointed in 1841, which documents his conflicted relationship among his peers in the Association of Medical Superintendents of American Institutions for the Insane (AMSAII). The book is divided into six chapters that follow the development of Eastern Lunatic Asylum chronologically, with a thematic focus on the individuals and groups that made up the institution's workforce, patients and daily routines.

Contrary to the beliefs of the majority of administrators within the psychiatric community of AMSAII, Galt opposed using physical restraints and rejected racial segregation in the asylum, despite his personal support for slavery. He further promoted the cottage system developed by psychiatrists in Geel, Belgium, which allowed for outpatient care of the asylum's charges by their families. Galt combined the cottage system with what he learned from the hiring-out system of southern plantations, and encouraged and arranged for free and enslaved patients to work in Williamsburg to support the asylum. Gonaver suggests that Galt adopted the herbal knowledge of slave healers, and complemented his university medical training by learning local plant remedies used among African Americans in Williamsburg (p. 23). Slavery influenced Galt's views on African Americans’ mental health, as he held that slave patients did not suffer anxieties caused by property holding or the ‘mental excitement’ produced by political discussions or new religious ideas (p. 32). Like other antebellum physicians, Galt professed that slavery drove human progress in a global sense, and derided abolitionism as a deranged and unhealthy form of madness. However, Galt did not embrace the scientific racism of craniometricians like Samuel George Morton or Josiah Nott. Unlike the scientists of the American School of Anthropology, Galt was a professed monogenist who believed Africans to be a biologically inferior, though anatomically similar, race to Europeans.

Enslaved staff members at Eastern Lunatic Asylum performed difficult and dangerous tasks. Caregivers exercised corporal power over free white patients as their labour, including bathing and administering medicine, brought them into close proximity. Women like Lavinia, Patience, Leticia and Harriet laboured at washing and dressing patients, cooking meals, farming food for the asylum, laundering clothes, emptying chamber pots and, occasionally, physically restraining patients who became violent. Gonaver highlights the ‘confusing intimacy’ of slave attendants, including those keeping watch over suicidal patients, whose work required them to exert physical power over white sufferers (p. 63). Several attendants allowed white and black patients to escape the asylum, and many themselves also absconded for periods of time (p. 79). Whether any of the enslaved attendants practised their own herbal medicine in the asylum is unclear; however, one woman, Louisa, demanded Galt pay her for performing conjure, or root-work, while treating patients in the asylum (p. 80).

Galt and other psychiatrists pathologized enslaved and free African patients, many of whom were women, as afflicted by delusional religious enthusiasm. Galt characterized religiously minded slaveholders who emancipated their slaves, such as the Swedenborgian planter Robert Carter III, as mentally unsound. Asylum staff treated enslaved and free patients who openly expressed their spirituality as epileptics. In an unpublished essay, Galt diagnosed the slave revolt leader Nat Turner as a ‘lunatic’ and cautioned psychiatrists that overenthusiastic religion signified a mental derangement that led to violence.

Asylum medicine exposed women patients to dangers within the hospital, especially sexual violence committed by male patients. Gonaver details several cases involving white and black women survivors of domestic assault who were later the victims of sexual assault and rape at Eastern Lunatic Asylum. Enslaved women attendants as well were the targets of rape by male patients. These cases shed light on how the social problem of violence against women became medicalized in the asylum as doctors diagnosed these women as sufferers of insanity. However, as Gonaver notes, doctors occasionally attributed insanity to social causes, notably ‘war’ and ‘freedom’ after Emancipation and the ratification of the Thirteenth Amendment in 1865 (p. 144).

After the Civil War, the state and the Freedmen's Bureau removed Eastern Lunatic Asylum's black patients to a new segregated institution, Central Lunatic Asylum. In the postbellum era Union asylum directors in Virginia reintroduced mechanical restraints for confining patients and rejected Galt's combination of plantation hiring out and the Belgian cottage model. By the end of Reconstruction, psychiatric administrators abandoned moral treatment in favour of a more strictly carceral approach to black mental hospital patients. Black institutions like Central State actively produced the dehumanization of African Americans through diagnosing patients as ‘imbeciles’, mass involuntary institutionalization, and farm labour that replicated the most debilitating aspects of slavery.

The Peculiar Institution and the Making of Modern Psychiatry, 1840–1880 illuminates how racist ideas influenced medical treatment at Eastern Lunatic Asylum despite the fact that Galt and his colleagues largely ignored the tenets of antebellum racial medical science. In contrast to the moral-therapy framework of Eastern Lunatic Asylum, mental institutions created in the late nineteenth century embraced moral hygiene and an ‘increasingly eugenic outlook’ that brutalized African American patients (p. 198). Gonaver's study of how racist attitudes built Eastern Lunatic Asylum will be valuable for scholars of African American history, race and health in the nineteenth-century US South.