"The asylum is up on the hill, but the lunatics are all over the State." So remarked James Petigru, an antebellum Unionist, when he heard of South Carolina's plans to secede from the United States. Petigru was obviously referring to insanity in political terms, but he inadvertently made an important point about insanity as a psychiatric condition. In contrast to what one might deduce from standard histories of mental illness in the 19th century, much of the care of the insane occurred not in asylums but in the community.

This point is made forcefully in Peter McCandless's Moonlight, Magnolias, and Madness, a history of insanity in South Carolina from colonial times to the early 20th century. McCandless began this project in the early 1980s, and it shows. He has done exhaustive research, finding references to the care of the insane in such records as those of the Charleston Commissioners of the Poor. Using these sources, McCandless shows how early South Carolina families struggled to care for noninstitutionalized, mentally ill family members who were often disruptive.

McCandless also examines inpatient care of the insane, providing a detailed history of the South Carolina Lunatic Asylum in Columbia (later the South Carolina State Hospital) from the time of its opening in 1828. Refuting earlier work, McCandless shows that the asylum was not simply a custodial institution but actively tried to cure its patients through "moral treatment." By the late 19th century, however, poor financing and overcrowding had transformed the asylum into a disease-ridden hellhole: "Bathrooms were often filthy, toilets overflowing, patients dirty and verminous." In addition, the use of bed straps, straitjackets, and other restraints, formerly discouraged, became routine. Given that South Carolina was the South's most ardent proponent of slavery, it is not surprising that hospitalized black persons during the Jim Crow era received particular neglect. Even the asylum's superintendent called the facilities for black patients "miserable cattle stalls."

Conditions for the mentally ill did not improve until the early 20th century. At that time, South Carolina enacted a series of long-overdue reforms that brought its care of the mentally ill back into "the American psychiatric mainstream." McCandless ends his narrative at this point.

Noting the often sketchy nature of the documents he has unearthed, McCandless is careful to avoid making definitive pronouncements on the history of insanity in South Carolina. Yet his ultimate conclusion—that the care of the mentally ill was influenced by such factors as class, income, race, and access to medical care—is somewhat disappointing. Having thoroughly examined a state with such a distinctive history of poverty, politics, and race relations, McCandless might have had more to say about how racial inequalities, cultural stereotypes, and local customs affected the very ways in which insanity was defined and understood. The need to confront such prejudices about mental illness remains a major issue for modern officials designing policies and treatment strategies.

Nonetheless, McCandless has begun to fill an important gap in our knowledge of the history of insanity. Although this book is probably too narrow and detailed for general readers of medical history, persons with a specific interest in mental illness or Southern history will find it rewarding.