In December 1924, the Austrian-born psychoanalyst Dr Dorian Feigenbaum reflected on the care of the mentally ill in Palestine. Writing from New York for an American audience, he drew on his experience as the medical director of a private Jewish asylum in Jerusalem, a position he had held from the end of 1920 to early 1923. It had not been a happy stint in office: the committee of the asylum, he recounted, ‘resisted every attempt to modernise the institution’, and were particularly alarmed by his attempts to introduce psychoanalytic methods. The picture he painted of the state of treatment for the mentally ill in Palestine was far from a happy one, either. But it was improving, in his view, thanks to the entry of the British into Palestine in 1917. Until that point, Feigenbaum wrote:

Feigenbaum noted that this ‘very sad though psychologically interesting chapter of cultural history’ was now coming to an end, thanks to the efforts of the newly created department of health, which had closed many of these old disreputable sites and established its own mental institution at Bethlehem. While underfunded and lacking specialists, it nonetheless represented an improvement on the private asylum in Jerusalem at which Feigenbaum had once been employed, and which he now – ties with his former employers severed – dismissed as being worse than useless, writing of the ‘hopelessness of a situation where the insane had to be treated in an old building, equipped with unsuitable and defective apparatus’.Footnote ²

In Feigenbaum’s telling, the British occupation of Palestine marked a dramatic rupture in the history of mental illness and its treatment. Both the British administration and a new generation of central European Jewish émigrés sought to introduce modern understandings and methods of treatment into Palestine, in the face of tight budgets, local superstition, and – in Feigenbaum’s case – outright opposition by an older generation of Jewish immigrants. A wealth of scholarship on late Ottoman Palestine and the British mandate throws this framing of the transition between empires into question, however. Rather than a slumbering backwater awaiting awakening by Europeans, historians have shown how Palestine and the Ottoman Levant were already being transformed by processes traditionally associated with modernisation across the late nineteenth and early twentieth centuries.Footnote ³ The First World War caused profound dislocation within the region. But in important respects the British and French mandates that emerged when the dust had settled were built on Ottoman foundations: not only were there continuities in terms of the social bases of colonial rule, and its developmentalist thrust, but even opposition to it was organised down the lines instantiated by the late Ottoman education and military system.Footnote ⁴

While the establishment by the British of a mental institution at Bethlehem in 1922 marked an important moment in the history of mental illness and its treatment, Feigenbaum – both playing to the presumed Orientalist hankerings of his audience and perhaps seeking revenge against his former employers – misrepresented the situation in Palestine before the 1920s. Certainly, the kind of treatment described by Feigenbaum was meted out by men of religion to the mentally ill. But it was far from the only option open to the families of the mentally ill before the arrival of the British. Both understandings of mental illness and methods of treatment underwent transformation such that by the eve of the First World War, Palestinians had recourse to Ottoman, colonial, and mission asylums across the region, as well as – closer at hand – hospices and hospitals within the territorial bounds of what became mandate Palestine itself. These institutions were not rendered obsolete by the arrival of the British; Palestinians continued to seek out relief and treatment at these institutions into the mandate period, while the new British administration, in turn, found its own approach to mental illness shaped in multiple crucial ways by the legacies of its Ottoman forebear. In this key respect, then, Palestine is distinctive within the history of colonial psychiatry, which has generally narrated the introduction of asylums, mental hospitals, and psychiatry itself as following the arrival of European colonialism; here, not least as a result of the fact that British rule in Palestine began so late, in the wake of the First World War, the colonial administration had to negotiate with both existing institutions and a population that was already familiar to a degree with psychiatry.

This chapter, then, does not seek to offer a history of the birth of psychiatry in the Middle East, nor of Palestine’s first encounter with modern methods of understanding and treating mental illness. Instead, at the heart of this chapter lies a messier set of encounters and negotiations that surrounded the establishment of the first government mental hospital at Bethlehem in 1922. What Feigenbaum represented as the breach of modern psychiatry into an antique land was, these encounters reveal, a more complex phenomenon. It grew out of a fraught relationship with existing institutions for the management of the mentally ill, and was as much a response to perceived crisis as the unfolding of any systematic plan for mental healthcare by the British. It was deeply contested, and by a surprising range of actors, from other branches of government to perhaps the most significant international humanitarian organisation operating in the region at the time. And rather than displacing that ‘very sad though psychologically interesting chapter of cultural history’, which Feigenbaum characterised as scarred by lurid stories of brutal abuse at the hands of men of religion, alternatives persisted, both because the British showed little interest in evangelising for psychiatry and because their provision never in any case kept pace with demand. This chapter ends by sketching the development of the first government mental hospital across the 1920s, with a focus on its staffing and on recovering a sense of the everyday lives of the patients who found themselves confined within it in this period. But to begin, we turn to the period before the British mandate, to explore what possibilities were open to Palestinians with mentally ill relatives in the last decades of the Ottoman empire.

Palestinian Encounters with Psychiatry in the Late Ottoman Empire

The government mental hospital established at Bethlehem in 1922 was a late addition to an already existing, complex landscape of therapeutic options open to Palestinians; one, moreover, that had been undergoing dramatic transformation in the decades before the First World War. In Istanbul and Cairo, vast asylums with histories stretching back centuries were reorganised and reformed under the Ottomans and, after 1882, the British in Egypt, while in Jerusalem and Beirut, new mission hospitals and private homes for the mentally ill were established. In spite of the stress placed by Feigenbaum and other European and North American observers on the abuse suffered by the mentally ill at the hands of men of religion, hospitals and doctors as well as monasteries and shaykhs played a role in the management of mental illness for at least some Palestinians in the late Ottoman period. Many of these institutions, including those that fell outside the borders of Palestine after the First World War, continued to receive Palestinian patients into the interwar years and beyond and, more than this, shaped the development of the mandate government’s own provision for the mentally ill in ways both obvious and subtle.

As in so many other areas of life, the last decades of Ottoman rule saw changes both in understandings of mental illness and in its treatment. For centuries, and in contrast to the emphasis placed by Feigenbaum and others on supernatural explanations of mental disturbances, humoral understandings of mental illness would have been familiar to physicians and at least some non-physicians too. Like its English counterpart, the Arabic term for melancholia (malikhuliya) – that is, depression – is derived from the Greek, meaning ‘black bile’.Footnote ⁵ This informed treatment, which would have centred on bleeding, bathing, and other interventions designed to rebalance the body’s humours. These treatments would generally have been undertaken within the setting of a bimaristan, which we might gloss as a hospital or a place of healing, which admitted those suffering from mental disturbances as well as bodily diseases such as leprosy, rather than within an asylum given over exclusively to the management of the mentally ill.Footnote ⁶ In addition to being sites of medical treatment, these institutions integrated gardens, fountains, and even music into their therapeutic regimens, as at the Bimaristan al-Arghun in Aleppo, which had been established on the site of a former palace in the fourteenth century.Footnote ⁷

While bimaristanat continued to operate well into the nineteenth century, they were judged to be in urgent need of reform by the late Ottoman period, especially as understandings of mental illness, its causes, and its treatment underwent change.Footnote ⁸ As Joelle Abi-Rached has traced, Arabic-language medical and scientific journals such as al-Muqtataf (The Digest) introduced and elaborated naturalistic accounts of mental disease to audiences in Palestine, as well as the rest of the Levant and Egypt, across the late nineteenth and early twentieth centuries.Footnote ⁹ In one article from 1905, for instance, al-Muqtataf described insanity in firmly bodily terms, as a disease of the brain, which could be due to weakened physical conditions resulting from a lack of nutrition or a lack of sleep, as well as a disease which might be inherited.Footnote ¹⁰ The journal introduced terms such as ‘psychology’ (bsikolojia) to Arabic-speaking audiences,Footnote ¹¹ but its focus tended to be less on mental disease and its treatment and more on putting this science to work to strengthen the mind. This was in line with the journal’s well-documented advocacy of Darwinian theories of evolution, and its wider emphasis on the need to ‘evolve’ in order to prevail in the struggle for survival with European states.Footnote ¹² Thus in a 1891 article on the prevention of diseases, the editors of al-Muqtataf included a warning – alongside cautionary notes about hypnosis, alcohol, opium, and other drugs – against overstraining the minds of students (ijhad quwa al-tilmidh al-ʿaqliyya) and neglecting their physical education (ihmal al-tarbiyya al-jasadiyya).Footnote ¹³

If the sciences of the mind were always about more than mental illness and its treatment, changing understandings were nonetheless accompanied by changing modes of treatment. Moral treatment – that is, a rejection of the use of physical restraint in favour of a more ‘humane’ strategy of encouraging reason and self-control – was introduced in asylums in Istanbul in the second half of the nineteenth century by an Italian physician appointed by the Ottoman state,Footnote ¹⁴ while British colonial doctors credited themselves with abolishing mechanical restraint and instituting reforms in the vast asylum at ʿAbbasiyya just outside Cairo in the years that followed the 1882 occupation of Egypt.Footnote ¹⁵ These asylums in Istanbul and Cairo would have represented treatment options to a small number of Palestinians in the late nineteenth and early twentieth centuries. In spite of the expansion of rail networks knitting together the empire, and the circulation of soldiers, students, and parliamentary delegates between Palestine and Istanbul, few Palestinians appear to have been admitted to Toptaşı asylum in Istanbul, the ‘official’ asylum of the Ottoman empire.Footnote ¹⁶ Across the 1880s, it was instead overcrowded Greek and Armenian asylums which provided many of the patients at Toptaşı.Footnote ¹⁷ A decade later, in 1897–8, just four patients from Syria and thirteen described as ‘Arabs’ were admitted to Toptaşı, of a total of four hundred admissions that year; it is not clear how many, if any, were Palestinian.Footnote ¹⁸ Cairo seems to have been as, if not slightly more, significant as an option for mentally ill Palestinians in the late Ottoman period. In the three decades following 1895, over four hundred Syrians were admitted to ʿAbbasiyya;Footnote ¹⁹ it would not be a stretch to imagine that at least some Palestinians were included in that figure.

If a trickle of mentally ill patients from across the Ottoman Levant made their way to Istanbul and Cairo over the late nineteenth century, in 1900, an alternative, much closer at hand, opened up to Palestinians with the establishment of the Lebanon Hospital for the Insane at ʿAsfuriyyeh, on the foothills of Mount Lebanon a few kilometres south-east of Beirut.Footnote ²⁰ The Lebanon Hospital for the Insane – renamed the Lebanon Hospital for Mental Diseases on the eve of the First World War – differed from the asylums at Toptaşı and ʿAbbasiyya in that it was not under the control of the Ottoman or British governments, but rather had been founded in the wake of a vigorous fundraising campaign throughout Europe and the United States by a sexagenarian Swiss Quaker missionary, Theophilus Waldmeier, and his wife, Fareedy Saleem. It was thus one of a number of educational and medical institutions established by European and North American missionaries from the mid-nineteenth century onwards as part of an inter-imperial and inter-denominational competition for influence and converts in the region,Footnote ²¹ though it is important, as Abi-Rached argues, to note the crucial support that Ottoman authorities and local elites extended to this project, too.Footnote ²² Marketed for many years as the only modern asylum between Istanbul and Cairo,Footnote ²³ the ‘humane care’ shown to patients at ʿAsfuriyyeh was represented as desperately needed to combat the prevailing superstitious, cruel treatment of the insane in the Levant.Footnote ²⁴

In a report issued soon after the hospital opened, Fareedy Saleem wrote about an exchange she had had with one of the patients, after he asked about the letters she was writing to subscribers:

As well as serving to showcase the hospital’s therapeutic success, Fareedy’s interlocutor also neatly captures a central dynamic in histories of psychiatry in the Middle East: the attempt by European missionaries and physicians from the late nineteenth century on to wrestle control of the mentally ill and responsibility for their treatment out of the hands of ‘men of religion’, and into the hands of ‘men of science’, as Eugene Rogan has put it.Footnote ²⁶ Two decades later, Feigenbaum reproduced a similar narrative of transition, this time to describe the impact of British rule in Palestine. But there is reason to be sceptical of this framing. At ʿAsfuriyyeh, for instance, successive medical directors found themselves locked in battle with the Waldmeiers, who – up to and beyond Theophilus’ death in 1915 – fought a determined rearguard action on behalf of the therapeutic value of religion in the hospital against these secular medical authorities.Footnote ²⁷ Rather than an accurate description, then, the transposition of madness from the domain of religion to the domain of science ought to be taken as a mission statement. ʿAsfuriyyeh’s supporters certainly represented the institution’s goal in this way, as being not only medical but educational. In 1909, the British Medical Journal hailed the hospital’s success in disseminating ‘the ameliorating influences of modern medical science and humanitarian zeal, not only among those dwelling in its neighbourhood, but to far-distant countries by travellers along the trade routes to Damascus and Baghdad, and even along the hajj road from Damascus to Mecca’.Footnote ²⁸ This had an apparently demonstrable impact on how mental illness was treated in Palestine: Dr David Watt Torrance, a Scottish doctor who had opened a missionary hospital in Tiberias in northern Palestine in 1885, reported how ‘[t]he members of certain Moslem families are the chief exorcists, but thanks to the ʿAsfuriyyeh, faith in them is dying out’, so that ‘[o]ne such practitioner was begging from me lately in Safad, saying he had nothing to do’.Footnote ²⁹

Indeed, Palestinians made their way to ʿAsfuriyyeh almost as soon as the mental institution opened its doors. In 1901, a Muslim merchant from Nablus and a Greek Orthodox blacksmith from Jaffa arrived at the hospital; both were discharged a few months later, without any improvement. A third admitted in the same year, a Jewish gardener from Jaffa, remained a patient for much longer; he was eventually discharged, apparently cured, in 1919.Footnote ³⁰ Over the next decade and a half, the hospital regularly admitted patients from other towns that would be incorporated into mandate Palestine, including Jerusalem, Haifa, Acre, Nazareth, and Bethlehem.Footnote ³¹ While the number of Palestinian patients admitted was not large, never exceeding twenty in any given year, they nonetheless represented a significant proportion of total admissions to the hospital across these years: in 1908, for instance, when seventeen patients from Palestine were admitted, the total number of admissions was just under seventy. Palestinians, then, made up a consistently significant proportion of cases at ʿAsfuriyyeh across the early twentieth century. This is perhaps unsurprising: towns in northern Palestine such as Haifa, Nablus, Acre, and Nazareth were administratively split off from Jerusalem and belonged instead to an Ottoman administrative unit centred on Beirut, a booming port city to which students, litigants, and merchants alike increasingly gravitated in the late Ottoman period.Footnote ³² And Jerusalem, the Ottoman provincial seat for southern Palestine, was itself only eleven hours by motor car from Beirut, according to one early post-war estimate.Footnote ³³

On the eve of the First World War, then, and in contrast to Feigenbaum’s exclusive focus on prevailing ‘religious and traditional prejudices’, decades of developments involving Ottoman, colonial, and missionary medical institutions meant that at least some Palestinians had recourse to asylums at Istanbul, Cairo, and – above all – Beirut. These changes in provision were paralleled, if not always directly undergirded, by the circulation of knowledge about the sciences of the mind in Arabic-language medical and scientific publications like al-Muqtataf. If Palestinians were embedded within these regional circuits of knowledge and therapeutic practice, there were also in the decades before the First World War options for treatment available even more locally, within the territorial limits of what became mandate Palestine. To round off this survey, then, let us consider three of the most significant of these institutions, all of which survived the cataclysm of the First World War and endured across the mandate years: the Ezrath Nashim home in Jerusalem; the hospice of the Sisters of St Vincent de Paul, also in Jerusalem; and the municipal general hospitals. While none of these institutions specialised in the treatment of the mentally ill, unlike ʿAsfuriyyeh and the other asylums at Istanbul and Cairo, they nonetheless admitted and cared for the mentally ill over the last decades of the Ottoman period, and so represented important localised options to the mentally ill and their families.

The Ezrath Nashim home, which Feigenbaum derided as ‘hopeless’ after his brief ill-fated stint as its medical director in the 1920s, had been founded in 1895 by a Jewish women’s charitable organisation. Established to provide succour to the growing number of European Jews arriving in Ottoman Palestine since the 1880s, the institution had started out life as the ‘Ezrath Nashim Home for the Insane and Incurable’ – at that time a single rented room within the Old City of Jerusalem – before it moved to a new site on Jaffa Road outside the city walls that had been acquired for the society by Baroness Rothschild. Initially it admitted mostly women, but a second building was added for male patients in 1910.Footnote ³⁴ By the end of the First World War, the hospital was accommodating an average of nearly fifty patients; by 1921, this number crept to over sixty.Footnote ³⁵ Though later publicity material emphasised the home’s mission of alleviating the suffering of the mentally ill, who ‘were left without any assistance and wandered around in a terrible neglected state uncared for, without food or clothing or any means of sustenance’,Footnote ³⁶ admissions statistics reveal that up until 1910, the home – true to its original, full name – consistently admitted more ‘incurable’ than ‘insane’ cases, that is, patients suffering not from mental illness but other chronic conditions.Footnote ³⁷ This ratio changed in the 1910s, as the home admitted larger numbers of insane patients, and indeed engaged ‘a specialist in psychical diseases’ to care for them.Footnote ³⁸ Though there were a handful of non-Jewish patients at the home in the early 1920s, shortly before the opening of the first government mental hospital at Bethlehem,Footnote ³⁹ it is not clear whether the home admitted many – if any – non-Jewish patients in the late Ottoman period.

A second institution that made provision for the mentally ill in late Ottoman Palestine was the hospice of the Sisters of St Vincent de Paul, or the Sisters of Charity, also in Jerusalem. In Palestine and especially Jerusalem, even more so than at Mount Lebanon, the nineteenth century was a period of ever more intense European diplomatic and religious competition for influence.Footnote ⁴⁰ While some missions appear to have embraced – with mixed success – medical work and founded hospitals as a means to legitimise their presence in the Holy Land and facilitate conversion,Footnote ⁴¹ it was central to the work of the French Society of St Vincent de Paul in Jerusalem, which was established in the mid-nineteenth century to administer relief to the sick and other cases of distress.Footnote ⁴² Though they were far from the only French order to provide charitable medical care in Jerusalem, the Sisters of St Vincent de Paul were, according to one early twentieth-century observer, unique among Christian societies in the city for their care for ‘the mentally afflicted’ at their convent outside Jaffa Gate:

As with many mission institutions, then, the hospice of the Sisters of St Vincent de Paul admitted patients from a range of backgrounds, not only Christians.

The Ezrath Nashim home and hospice of the Sisters of St Vincent de Paul reflect two very different external influences shaping healthcare in late Ottoman Palestine. But external actors were not the sole drivers of change, as is now well established in the historiography,Footnote ⁴⁴ and developments in healthcare need to be understood against the backdrop of wider reforms and initiatives by both the Ottoman central government and more local actors. From the 1870s, the Ottoman state tasked municipalities across the empire with a range of responsibilities, including security, infrastructure, justice, and education, as well as health and sanitation.Footnote ⁴⁵ In Palestine, the municipalities of three of the most important towns – Jerusalem, Jaffa, and Nablus – came to establish and run hospitals as a result. While these were generally funded out of municipal tax receipts, the Watan or ‘National’ hospital in Nablus was built in 1888 using donations from local residents instead,Footnote ⁴⁶ suggesting that investment in healthcare was not solely a concern of central government in late Ottoman Palestine; indeed, this hospital predated the municipal hospital at Jerusalem by several years. At Jerusalem, a city crowded with missionary hospitals, the municipality funded a municipal doctor, a municipal pharmacy, and – in 1891 – a municipal hospital, all of which served the whole population of the city.Footnote ⁴⁷ The municipal hospital recruited its staff from a range of backgrounds, too, hiring Greeks and Jews as physicians and drawing on Catholic women’s orders – including the Sisters of St Vincent de Paul – for its nursing staff.Footnote ⁴⁸ Though these municipal hospitals did not make specific provision for mental illness, the mentally ill nevertheless ended up being treated within them and in other general hospitals across Palestine in the interwar years;Footnote ⁴⁹ it would be remarkable if municipal hospitals, like the hospice run by the Sisters of St Vincent de Paul, had not occasionally taken in and cared for the mentally ill in the late Ottoman period too.

While the birth of the asylum, or the introduction of psychiatry, have been focal points in histories of colonial psychiatry, in the case of Palestine, both the modern sciences of the mind and institutions that provided care – if not always medical treatment – for the mentally ill predated British rule by decades. This is not to say that the founding of the first government mental hospital at Bethlehem in 1922 was unimportant: provision for the mentally ill within the territorial bounds of what became mandate Palestine was undeniably limited in the late Ottoman period, and access to more specialised institutions at Istanbul, Cairo, and even Beirut would have been beyond the reach of many. But rather than representing a brand new start for the care of the mentally ill in Palestine, as Feigenbaum suggested, the first government mental hospital needs to be set within a longer and more complex history of the expansion of therapeutic options available to the mentally ill and their families from the middle of the nineteenth century onwards. External actors, including the British in Egypt, Christian missions throughout the Levant, and European Jewish charitable societies, as well as the Ottoman central state, municipal governments, and local society, shaped this history. And far from being simply the historical backdrop to the story of psychiatric provision by the mandate, many of the institutions founded in the decades before the mandate continued to admit and treat Palestinians right across the mandate period and indeed beyond it, too. Indeed, as we will now see, those therapeutic options available to late Ottoman Palestinians did not simply continue into the mandate period and coexist alongside new government institutions, but crucially shaped the British mandate’s approach to the question of mental illness across the 1920s and beyond.

Figure 1.1 Photograph of the Convent of the French Sisters of St Vincent de Paul, outside Jaffa Gate in Jerusalem, dated 1920.

From the Eric and Edith Matson Photograph Collection, Library of Congress.

The Devolution of Health and the Post-war Crisis in Provision for the Mentally III

The government mental hospital at Bethlehem first opened its doors to patients late in 1922. While this might appear precocious, given that the British mandate for Palestine was only confirmed that same year, in a sense it fits a broader pattern in the history of British colonial psychiatry. Over the nineteenth century, colonial lunatic asylums had been slow to emerge in British India, with Burma, for instance, provided with a lunatic asylum only in 1870.Footnote ⁵⁰ But by the start of the twentieth century, and in the context of British colonialism in sub-Saharan Africa, frequently a gap of only a few years separated the formal establishment of British protectorates and the opening of lunatic asylums – or, more often, a lunatic ward appended to colonial prisons.Footnote ⁵¹ Even set against this wider shift in the history of colonial psychiatry, however, it is remarkable that expenditure for a government mental hospital had been approved for Palestine in July 1918, before the British had even secured the northern half of the country.Footnote ⁵² Why, with the war still raging, was the establishment of some kind of mental institution even on the agenda of the interim occupying administration? In part, the sense of urgency that surrounded the establishment of a government mental hospital emerged out of the fraught relationship between the new British administration and those institutions that predated their arrival. The drive to take responsibility for mental illness derived less from any systematic plan for healthcare and more from a sense that the existing arrangements for the management of the mentally ill were breaking down and could not be relied upon. In that respect, the seemingly precocious British attention to this question turns out to have been, as in so many other instances from across the history of colonial psychiatry, a form of crisis management.Footnote ⁵³

In the first years of British rule in Palestine, responsibility for the mentally ill was delegated to existing institutions. This was in line with the administration’s wider policy of decentralisation when it came to healthcare. While the British committed their resources to anti-malaria measures, as ‘an essential preliminary to all other steps for the moral and material improvement of the country’,Footnote ⁵⁴ general public health and the provision of hospital accommodation were left to others: general public health measures like sanitation and inspections to municipal and rural councils; and hospitalisation initially to an assortment of international organisations, notably the American Red Cross and Zionist organisations.Footnote ⁵⁵ The post-war withdrawal of the American Red Cross, and a fall in funding from Zionist organisations, meant that the burden of providing hospital care passed on to other voluntary and charitable institutions, in particular mission hospitals. Rather than making up any shortfall in provision, the government’s policy of devolution only deepened in the early 1920s, with general hospitals established or taken over by the government during the war at Gaza, Nablus, Jaffa, Beersheba, and Acre handed over to their respective municipal authorities by 1925.Footnote ⁵⁶

In keeping with this wider policy of devolution, then, the government relied on the Ezrath Nashim home in Jerusalem to provide accommodation for the mentally ill in the immediate post-war years. But – in striking contrast to its approach in other areas of health – the government very quickly began to make plans to relieve itself of dependence on this private institution. In part, this was a question of finance. The cost of subsidising the Ezrath Nashim home spiralled in the immediate post-war years. While in 1919 the government had subsidised the asylum to the tune of £600, this figure rose rapidly; the subsidy was more than double this initial amount for the first half of 1921 alone.Footnote ⁵⁷ George W. Heron, director of the new department of health established in 1920, expressed alarm at the sums of money being handed over to this institution, which had – in spite of the ever-growing subsidy – nevertheless managed to rack up a significant debt. In part, this was a result of a failure to re-capture the private donors who had supported the Ezrath Nashim society before the war disrupted this arrangement. But in part the debt was also a result, Heron complained, of ‘reconstructions and alterations of the building effected this year which, under the circumstances, were hardly justified though no doubt desirable’.Footnote ⁵⁸ His characterisation of this work as excessive was disputed on behalf of the society by Margalit Meyuchas. Far from unnecessary, this work had been precipitated by the government’s recognition of the asylum as a ‘necessary institution’. It was, after all, she argued, ‘by virtue of the government having sent its own patients there that the asylum was obliged to widen the sphere of its activities’.Footnote ⁵⁹ This had included not only the extension of the home’s physical fabric, but the hiring of a specialist from Europe to direct the institution in 1920: Dorian Feigenbaum, still in post late in 1921 when this dispute was ongoing. From their perspective, it was not mismanagement but rather the failure of the government to properly subsidise this ‘necessary institution’ which had left the Ezrath Nashim home in debt.

What Heron and Meyuchas agreed on was that the Ezrath Nashim home had undergone significant changes in the post-war years. Some of this, as Meyuchas reminded Heron, was a direct result of government intervention. While the balance between ‘insane’ and ‘incurable’ residents at the home had been shifting in favour of the former already by the 1910s, in 1921 the government used an Ottoman-era law regulating asylums to forbid the admission of any other patients besides those who were mentally ill into the home.Footnote ⁶⁰ The institution ceased to be a home for the incurable and insane and became instead a home for the insane only. This, as the society noted, had a knock-on effect on discharge figures: as the number of ‘incurable’ cases in the home declined, the number discharged dramatically increased. In 1921, for instance, eighty-two ‘insane’ patients were admitted, and sixty-three discharged.Footnote ⁶¹ The increasingly rapid turnover in patients fed into a second major trend in terms of admissions in the post-war years: the skyrocketing number of mentally ill patients admitted on a yearly basis to the home, from an average of just twenty during the war, to quadruple that figure by the early 1920s. While this was offset to a degree by the higher discharge rates, it is clear that the home had become seriously overcrowded. In March 1922, pressure on the home was so severe that the society wrote to Heron to ask whether a barracks could be put at its disposal to accommodate patients, as ‘all beds are permanently occupied (including the reserve-beds)’.Footnote ⁶² A final change in admissions can also be linked directly to the government’s policy of delegating responsibility: while a majority of patients in the home continued to be Jewish, by the early 1920s around a third of patients at the home were Christian or Muslim.Footnote ⁶³ Their costs were directly met by the government, though Heron appears to have been uneasy about the prospect of Jewish and Muslim patients, in particular, being accommodated together.Footnote ⁶⁴

Figure 1.2 Changing admission patterns at the Ezrath Nashim hospital, 1895–1922.

Figures taken from Bulletin No. 20, for 1922, of the Home for the Insane and Incurable founded by the Ezrath Nashim Society, Jerusalem (1923), ISA M 6627/33.

More than just the patient demographics or the physical fabric of the Ezrath Nashim home was undergoing transformation in the early 1920s. In keeping with its new government-enforced focus on the mentally ill alone, the society hired a specialist in mental diseases from Europe: Dorian Feigenbaum, who was appointed medical director of the home in 1920. Feigenbaum, looking back with some bitterness after his time at the home was brought to an abrupt end, complained he had been blocked from enacting much-needed changes by the society’s conservative governing committee. But it is clear that things did change in this period. Feigenbaum himself travelled widely over the course of his short stint in Jerusalem in order to learn from other institutions in the region and gather examples of best practice that he could introduce at the Ezrath Nashim home: in the autumn of 1921, he went to Beirut, presumably to visit ʿAsfuriyyeh;Footnote ⁶⁵ in January 1922, he departed on a tour of mental institutions in Egypt and Europe.Footnote ⁶⁶ By 1922, hydrotherapy was in use at the Ezrath Nashim home, suggesting that rather than simply providing hospice care, it was attempting to actually treat the mentally ill.Footnote ⁶⁷ And Feigenbaum sought to shape government policies too. He offered to give a course of lectures for ‘both Jewish and Arabic policemen’, with demonstrations, to ensure mentally ill patients were handled properly by policemen when they fell into their charge.Footnote ⁶⁸ Indeed, in June 1921, midway through Feigenbaum’s time in post, the Bishop in Jerusalem visited the Ezrath Nashim home and lavished praise on ‘the order, the cleanliness, and the freshness of these rooms’, the ‘unceasing care and effort on the part of the doctor and his staff’, and even ‘how wonderfully cheerful and happy most of the patients were’.Footnote ⁶⁹ If this account is a stark contrast to Feigenbaum’s later critical assessment of the institution, in the end Feigenbaum’s innovations led to his downfall: after a series of lectures on the unconscious, dreams, and the Freudian theory of neurosis, he was dismissed from his post. As Eran Rolnik puts it, this marked the ‘abrupt and early end to the first attempt … at a practical application of psychoanalytic theory’ in Palestine.Footnote ⁷⁰ More than this, it can hardly have inspired confidence that the government’s money was being put to good use by this private institution.

While the Ezrath Nashim home clearly had problems, financial and otherwise, by the early 1920s, it seems to have been less hopeless than either Feigenbaum or George Heron, the director of health, represented. Feigenbaum’s motive in exaggerating the failings of his former employer is clear, but Heron’s criticism of the institution for its unjustifiable expenses too can be related to his career and worldview. Heron – who was to remain director of health for almost the entirety of the period – had been a physician in London before taking up a post with the government of British-ruled Egypt in 1908. That he came to Palestine in 1920 through the colonial service in Egypt was, as Marcella Simoni argues, not incidental to his attitude in his new role as director of health: rather than treating Palestine as a special case because of either the mandate or Zionism, he believed that the same standards and practices should be applied in Palestine as across the rest of the British empire.Footnote ⁷¹ It is through that lens that the ‘excesses’ of this private Jewish mental institution, with its spiralling subsidies, renovations, and psychoanalytic flirtations, may have come to represent a good enough reason in Heron’s mind to sever the government’s connection with it. As we will see, his background in the colonial medical service may also explain his anxiety about ‘mixing’ Jewish and Muslim patients in this institution.

Whatever lay at the root of Heron’s views, the perceived mismanagement of the Ezrath Nashim home posed a dilemma. Other institutions were allowed to simply fail: the general hospital at Tulkarm closed its doors in February 1925, when the municipality proved unable to contribute to its continued upkeep.Footnote ⁷² But madness was different, not least because it always represented a potential threat to public order as well as a question of health, as Heron himself emphasised repeatedly in the early 1920s. It was a matter of ‘great urgency’ that ‘lunatics at large or confined in prisons … be properly accommodated’, as he put it, conjuring a calculatedly alarming vision of lunatics roaming the streets unchecked, threatening public safety.Footnote ⁷³ Given the rising cost of subsidies and the perceived mismanagement of the Ezrath Nashim home, the only option left was for the department of health to assume direct responsibility for the mentally ill by pushing ahead with the establishment of a government mental hospital, for which expenditure had already, after all, been approved. Rather than a result of any comprehensive plan for healthcare in Palestine, it was to save the government from ever more costly reliance on the Ezrath Nashim home that the first government mental hospital was established.

This is a stark contrast with the existing scholarship on healthcare in mandate Palestine, which often offers a very different narrative: that it was the failings of the government’s provision that in part meant private Jewish provision expanded so dramatically over the 1930s and 1940s, in order to pick up the slack.Footnote ⁷⁴ In the 1920s, at least, it might be argued the reverse was true: it was the perceived shortcomings of private Jewish provision that prompted the entry of the government into this field. But what the department of health’s earliest interactions with the Ezrath Nashim home help illustrate is the extent to which the histories of private Jewish provision and colonial governmental provision for the mentally ill were intertwined. While a focus in the scholarship has been the gap in quality and indeed scale which opened up, especially over the course of the 1930s, between the more sophisticated private provision made by European Jewish psychiatrists and the always substandard, underfunded provision made by the mandate, for the 1920s at least a different story emerges. The two spurred one another on: by thrusting responsibility on the Ezrath Nashim home and enforcing Ottoman-era asylum regulations, the British drove the transformation of that private institution; in turn, attempts at reform within the Ezrath Nashim set alarm bells ringing within the department of health such that they moved to establish their own mental hospital, in a striking departure from their commitment to a policy of devolution in healthcare more widely.

The Ezrath Nashim home was not the only institution to admit and care for the mentally ill in Palestine before the arrival of the British, nor was it the only one of those institutions to find itself in a closer relationship with the new government after the end of the war. While the British sought to devolve as much responsibility for health as possible to other actors, in the immediate aftermath of the war municipal hospitals were run as government hospitals and only gradually handed over to the municipalities across the early 1920s. Mission hospitals too found themselves under scrutiny. Late in 1925, for instance, the department of health stepped in when it emerged that the Sisters of St Vincent de Paul were treating patients at the convent’s clinic in Jerusalem with ‘poisonous drugs’ which, it was feared, the Sisters were ‘likely to misapply … with very disastrous consequences to the patient’.Footnote ⁷⁵ But although these other institutions had also played a role in managing the mentally ill in the late Ottoman period, it was to the Ezrath Nashim home alone that the British turned for a solution to the problem of the mentally ill, at least initially. In a sense, this is consistent with what Jacob Norris has identified as the key shift between development under the Ottomans and the British: whereas the world of Ottoman development was a mixed, multifarious one, the British focussed more exclusively on European Jews as agents of development in Palestine.Footnote ⁷⁶ But as the department of health’s attempts to end its dependence on the Ezrath Nashim home suggest, the story of health does not map neatly onto the story of development, and within the history of health, mental illness generated particular anxieties and specific responses.

If inheritances from the late Ottoman period helped shape many aspects of British rule in Palestine, they mattered in different ways. In terms of mental illness, the endurance of institutions which had cared for the mentally ill before the war made it possible for the government to delegate responsibility initially, but ultimately it was the perceived breakdown in those arrangements that mattered, as a spur to the establishment of a government mental institution. The speed and sense of urgency with which the first government mental hospital was established can be seen, at least in part, as a result of this perception of crisis, but this was not the only dimension to this story. Nor was the Ezrath Nashim society the only actor with which the department of health had to negotiate in these early years. The question of where this new mental hospital was to be located also proved contentious and threw the department of health into a confrontation not just with other branches of the civil administration but international humanitarian organisations – as we shall now see.

Orphans, Lunatics, and the Struggle over a Mental Hospital in Bethlehem

One of the reasons the department of health was forced to tolerate the continued devolution of responsibility for the mentally ill to the Ezrath Nashim home, even as the cost of subsidies to the home spiralled, was the difficulty in identifying a suitable site for the proposed government mental hospital.Footnote ⁷⁷ But by 1922, the department of health had settled on an orphanage on the outskirts of Bethlehem and had made arrangements to lease it from the German missionary society which had built and run the institution and which still owned the site. The decision to convert this orphanage into a mental hospital aroused fierce opposition from a strikingly broad coalition, including local society, branches of the British civil administration, and international humanitarian organisations. In the face of this opposition, and in particular calls for the orphanage to take in Armenian children displaced in the Ottoman wartime genocide, the department of health was pressed to articulate an ambitious vision of the nature of this mental hospital – and more than this, to counter perceptions of the mentally ill as ‘useless’ members of society. These confrontations, then, offer a window into the conceptualisation of mental illness in the early years of British rule in Palestine, a theme that will be developed further in the second chapter.

The orphanage eyed up by the department of health in the early 1920s had been built by a German mission organisation, the Berliner Evangelische Jerusalem Verein, in 1896 to look after dozens of Armenian children orphaned and displaced in the massacres of that decade.Footnote ⁷⁸ Over the years, as the Armenian orphans aged out of the institution, the orphanage came to take in Syrian orphan children;Footnote ⁷⁹ in the immediate aftermath of the British occupation, it appears to have continued to operate as an orphanage for boys.Footnote ⁸⁰ The site itself is worth describing, not least because the contestation over its future and the department of health’s determination to make use of it cannot be understood without a sense of this location and its buildings. Hailed as ‘one of the best and most favourably situated buildings’ in Bethlehem,Footnote ⁸¹ the orphanage was located just to the south-west of the town, on the road between Bethlehem and the nearby village of Artas, and consisted of a three-storey main building flanked by symmetrical wings and set in grounds of 20 dunums, or around 5 acres, of land. Photographs of the time make clear both its distance from the town of Bethlehem and its handsome construction, built using pale limestone.Footnote ⁸² It was this stone – ‘Jerusalem stone’ – that Ronald Storrs, the governor of Jerusalem in the immediate post-war years, mandated should be the face of all new buildings in the city in an edict of 1918, making local limestone the only material allowed on external walls within the vicinity of Jerusalem.Footnote ⁸³

Storrs also happened to be one of the most vociferous opponents of the orphanage plan. In April 1922, Storrs wrote furiously to the chief secretary of the government with a formal protest against the conversion of the orphanage into a lunatic asylum, in particular, and the placing of a lunatic asylum anywhere in Bethlehem, in general. The move was one he considered ‘unsuitable and prejudicial to the interests of one of the most important towns in my district and indeed of Palestine’.Footnote ⁸⁴ As well as the proprietorial manner in which Storrs wrote about Bethlehem, what is notable about this protest is its echo of the purpose of the Pro-Jerusalem Society, which Storrs had founded in autumn 1918: that is, ‘the preservation and advancement of the interests of Jerusalem, its district and inhabitants’.Footnote ⁸⁵ The contention that the use of this site as an asylum would not serve the interests of Bethlehem was not unique to Storrs, but there was a clear aesthetic as well as practical dimension to his protest. Storrs’ efforts to ‘preserve’ Jerusalem’s character led to aggressive interventions into the physical fabric of the city, reversing late Ottoman developments, in order to rework it to fit romanticised British notions of what the city should look like.Footnote ⁸⁶ It is hard not to see his rejection of the siting of an asylum in the vicinity of Jerusalem and Bethlehem as stemming from his circumscribed views about what was appropriate to the character of ‘his’ district, especially given that the building itself, no matter how recent in provenance it was, could otherwise be held up as a superb example of the stone-clad aesthetic he had made mandatory for all buildings in the vicinity of Jerusalem. The idea that mental illness might be a symptom of industrial modernity was a well-established one from the nineteenth century on; here, however, there is a sense that a site for the treatment of mental disease might also constitute something of a loss of innocence, an unwelcome breach by modernity into a supposedly biblical environment.

Storrs was not the only opponent of the orphanage plan, nor its most dogged critic. Shortly after Storrs registered his own formal protest, Harold McAfee, the Beirut director of the American humanitarian organisation Near East Relief, approached the government in Palestine for permission to take charge of the site to accommodate some of the 100,000 orphans which the organisation found in its care after the First World War.Footnote ⁸⁷ Given that many of these orphans were Armenian, McAfee presented Near East Relief’s proposed takeover of the Bethlehem site, ‘built by benevolent contributions contributed specifically for the erection of an Armenian orphanage’, as a fitting return to its original purpose.Footnote ⁸⁸ He was deeply dismayed to learn the government planned to convert it into a mental hospital, and across the rest of the year McAfee sought to reverse this decision. He argued, in a meeting with the chief secretary in the summer of 1922, that ‘alienating a building, the original purpose of which was to support and educate orphans to be useful members of society in order to house forty individuals who were incapable of being useful citizens, was not a policy in keeping with the interests of the country’.Footnote ⁸⁹ McAfee’s insistence was one born in part of desperation. In 1922, Near East Relief was urgently seeking a new place of refuge for Armenians who had already been repatriated in the immediate aftermath of the First World War to French Cilicia in southern Anatolia, but who had been displaced once again in 1920 when Turkish forces under Mustafa Kemal drove out the French, captured Marash, and massacred thousands of Armenians in the city.Footnote ⁹⁰ But his insistence on the value of supporting and educating orphans also spoke to a wider shift in the aims of Near East Relief. Originally founded to provide immediate relief in the form of food during the war, after 1918, as Keith Watenpaugh has argued, the organisation developed a more far-reaching vision of humanitarianism, which went beyond fixing immediate suffering to reforming social and political systems across the region. And at the heart of this more expansive project was the rearing, by Americans, of a transformational new generation of orphans.Footnote ⁹¹

While Near East Relief had a particular stake in the question of the support and education of orphans, their strategy of contrasting ‘useless lunatics’ with orphans who could go on to make valuable contributions to society resonated within the government of Palestine. This was not least because, as Emily Baughan notes, this was a transitional moment in British imperial politics, within which humanitarian work on behalf of children was folded into a post-war reconceptualisation of empire as a moral force.Footnote ⁹² No such moral cachet was attached to supporting lunatics, a term left undefined but which here was nonetheless clearly understood as denoting those suffering severe and untreatable afflictions of the mind. At a meeting of high-ranking British officials convened in Jerusalem in August 1922, then, when McAfee’s criticisms were relayed, they found support among a number of those present. Norman Bentwich, attorney general, agreed ‘[i]t seemed a pity that the orphans should suffer for the advantage of lunatics, who could be accommodated anywhere’. While the chief secretary distanced himself from McAfee’s description of lunatics as ‘useless’, he nevertheless was sympathetic to the use of ‘the expression to contrast the lunatics with the orphans as the two were at opposite ends of the social scale’. Moreover, he noted this was a position shared by the people of Bethlehem, whom he described as ‘averse to an asylum being installed in what was perhaps one of the best and most favourably situated buildings in their town and this in place of a useful institution such as the orphanage’.Footnote ⁹³ This was the only time local opinion was raised in relation to the proposed conversion of the orphanage; much more attention was given to critiques from other branches of the government and from Near East Relief than Bethlehemites themselves.

As these comments make clear, the conversion of the Bethlehem orphanage into a mental hospital revealed not only a fault line in the relative valuation of orphans and lunatics, but deeply divergent understandings of the mental hospital itself. It was not only orphans but the orphanage which were figured as useful, and it was not only lunatics but the mental hospital – or asylum, the older term deployed by many of these officials – which were dismissed as useless. This dismal view was not atypical: it reflected wider pessimism by the early twentieth century about the curability of the mentally ill and the therapeutic value of institutions which had become silted up with incurable cases across the preceding century.Footnote ⁹⁴ But J. W. P. Harkness, standing in for the director of health at this meeting, offered a forceful counterargument. Far from patients at the hospital being ‘useless members of society’, he contended that ‘it was expected, with the facilities afforded by adequate accommodation, to have a reasonable percentage of cures’. Indeed, even while still patients in the institution, he noted, they would be employed in different forms of work which would in turn help support the running of the hospital and reduce the cost to government. And far from accepting Bentwich’s argument that lunatics could be accommodated anywhere, he argued that ‘the modern principles of treatment required that if insane people were to be treated with any hope of cure they must be accommodated and treated under the best conditions possible’. Bentwich’s response was revealing: ‘this was all right in a civilised country’ – the implication being that for a country like Palestine, it was an unaffordable extravagance. It was not simply divergent understandings of the mental hospital at stake here. This was also a debate, at a formative moment for British rule in Palestine, over the nature of that rule. Was the purpose of British rule in Palestine to ‘preserve’, as Storrs would have it, and adapt and indeed lower expectations to fit the perceived requirements of the country, as Bentwich was suggesting? Or was British rule to strive to reproduce standards imported from Britain itself, as Harkness contended in outlining his vision of a modern mental hospital, and as the mandate itself, formalised just a month earlier by the League of Nations, with its injunction to progress under European ‘tutelage’ might have been taken to mean?

In the end, and in the face of such opposition, the department of health had to marry this argument about the recoverability of the mentally ill if given proper treatment to a warning about the danger posed by lunatics left at large, suggesting their inability to force any consensus on the nature of British rule in Palestine. Citing an incident from 1921, in which several people had been killed, and others wounded, ‘through the action of a person of unsound mind’,Footnote ⁹⁵ Harkness sought to alarm the government into supporting the department of health’s plan. Yet, his appeal to security concerns sat uneasily with his emphasis on treatment and recovery, rather than restraint and criminality, a contrast that serves to underline what was distinctive about mandate Palestine. Across other British colonies in the early twentieth century, provision for the mentally ill grew out of the prison system, with the first asylums little more than prison annexes instituted to separate out the insane from the sane.Footnote ⁹⁶ By contrast, in Palestine the government approached the question of provision for the mentally ill as a matter for the department of health from the beginning, with provision for ‘criminal lunatics’ only developed years later.Footnote ⁹⁷ This was an attitude shaped at least in part by advice from colonial medical authorities in Egypt, whom the early department of health in Palestine consulted extensively on the establishment of the first government mental hospital. Their guidance was very clear: asylums should be attached to hospitals, rather than prisons, to eliminate the stigma associated with being certified as a lunatic. De-stigmatising admission to asylums would encourage people to come forward sooner for treatment, allowing for earlier, and possibly more effective, interventions.Footnote ⁹⁸ The invocation, then, of the mentally ill who committed acts of violence – the kind of ‘lunatic’ that McAfee, Bentwich, and others had in their minds when they used the term – should be understood as strategic, a move made by the department of health to outmanoeuvre opposition, but one that sat uncomfortably with its wider effort to treat mental illness firmly as a health, rather than criminal, issue.

The department of health ultimately carried the debate, securing the site for a government mental hospital. The opposition generated by this plan may have failed to derail the conversion of the site, but it was not entirely without effect: it forced the department of health to articulate, more explicitly than might otherwise have been the case, a vision of the government mental hospital as a place of cure rather than mere confinement, and thus as requiring not just any old site – as both McAfee and Bentwich proposed – but a spacious, open, attractive site in which patients had a hope of recovery. While Feigenbaum presented the British as straightforwardly bringing modern psychiatry with them to Palestine, the controversy which surrounded the first government mental hospital suggests that even at the highest rungs of the new government, there were divergent views about quite what a mental hospital was, and whether one was, in fact, suitable for Palestine.Footnote ⁹⁹

The department of health, in spite of the urgency of the need to find an alternative to the Ezrath Nashim home by 1922, was determined that the right site be acquired for a proper mental hospital, even if it meant confronting a coalition of actors within and beyond the government who opposed their plan. In one sense, this commitment to an ambitious vision of a mental hospital in Palestine, while clearly deeply held enough to ensure the department fought off opponents, seems at odds with the highly critical attitude Heron had adopted towards the – in his view – unwarranted, excessive undertakings of the Ezrath Nashim home the previous year. Was the department’s own scheme, as government officials like Bentwich had suggested, not also open to the same criticism, as inappropriate, excessive? In another sense, however, both the department’s frustration with the Ezrath Nashim home, and their determination to acquire this site, can be seen as consistent: it was precisely the fundamental issue of siting which made, on the one hand, the Ezrath Nashim home, located in the most important and busiest extra-mural area of Jerusalem, an unfit site for expansion and, on the other hand, the German orphanage outside Bethlehem a suitable site for investment. The department’s aspirational vision of this mental hospital should be taken seriously – no matter how short of that ideal the reality subsequently fell, as we shall see later in this chapter.

Figure 1.3 Photograph of the ‘German’ [Jerusalem Verein] orphanage at Bethlehem, before the First World War.

From the Hallwyl Museum Collection, Inventory Number LXVI: N.78.

Figure 1.4 Photograph of Bethlehem from the west, with the buildings of the Jerusalem Verein’s Armenian Orphanage visible on the left of the image, dated 1898.

From the Eric and Edith Matson Photograph Collection, Library of Congress.

From Monastery to Mental Hospital

Before we turn to explore the early years of its life, there is a third and final dimension to the story of the founding of the first government mental hospital, one that returns us to the question of non-medical ‘alternative’ modes of understanding and treating mental disease which Feigenbaum, Waldmeier, and others emphasised in their writings for western audiences. In Feigenbaum’s telling, it was not just the inadequate Ezrath Nashim home that was eclipsed by the British arrival into Palestine. The new government also moved to close down those abusive, ‘superstitious’ methods of treatment meted out by priests, shaykhs, and others in the region. But as with much of Feigenbaum’s account, this narrative of transition – in which mental illness was displaced from the domain of religion to the domain of science – does not quite capture what happened to non-medical methods of treatment in the first years of British rule in Palestine. The first government mental hospital, with its suggestive proximity to a monastery of St George that had previously received and treated the mentally ill, here acts as a point of departure for thinking differently about the relationship between these purportedly oppositionary traditions, as blurring into rather than always competing with one another.

While Palestinians had recourse to a number of medical institutions – general or specialist, governmental or missionary, in Palestine or further afield – when mental illness appeared in their midst in the decades before the First World War, their options also included non-medical, as well as medical, remedies. Feigenbaum’s myopic focus on superstition prior to the arrival of the British is misleading, but much of what he has to say about the non-medical treatment of the mentally ill finds corroboration in other accounts from the time itself. As the Arabic aphorism has it, al-junun funun: madness takes many forms. Thus alongside both an older humoral understanding of forms of mental illness like melancholia, and the naturalistic account of mental disease elaborated in the pages of journals like al-Muqtataf in the late nineteenth century, the idea that supernatural agents – above all the jinn – might be responsible for madness continued to hold purchase. The line between different states was not always clearly demarcated, as Sara Scalenghe highlights: while one might be recognised as a ‘holy fool’ (majdhub) – a saintly individual with a special connection to the divine and the capacity in some cases even to perform miracles – it was equally possible to be dismissed as insane, or denounced as a heretic; the boundaries between these states were blurred in practice.Footnote ¹⁰¹ And far from these beliefs being confined to the ‘ignorant’ peasantry, James Grehan notes that spirits were judged real enough for jurists to debate and make rulings against the legality of marriages with jinn.Footnote ¹⁰²

Just as humoral or naturalistic understandings of mental disease shaped medical treatment, so too did these beliefs in the supernatural origins of some mental illnesses, documented in folklore research by European and North American visitors as well as by Palestinian ethnographers in the interwar years, shape treatment. The American Ada Goodrich-Freer, who arrived in Jerusalem in 1901 and was herself a psychical researcher, elaborated on this. The Muslims of Palestine, she wrote, ‘assume (who knows with what justice?) that insanity is due to the presence of an evil spirit’, and that as a result ‘their treatment is based on the theory of exorcism, of making his tenement unpleasant’. She described how the insane were ‘sometimes shut up under the Haram area, or chained to a pillar in the church at al-Khader, or sent to the cave of Elijah’. At these sites across Palestine, she wrote, the ‘awful sacredness of the place’ might well shock them out of their insanity.Footnote ¹⁰³ While we might expect Goodrich-Freer – spiritual medium and psychical researcher – to be less sceptical of a form of treatment that relied on supernatural agency, Thomas Chaplin, trained as a medical doctor, reached a similar conclusion: he suggested that this treatment worked in the same way any sudden fright might, ‘producing a kind of shock to the nervous system which proves beneficial’.Footnote ¹⁰⁴ Chaplin was not alone in giving a medical rationalisation of this treatment. Writing for a psychiatric medical journal in the 1880s, the French psychiatrist Jacques-Joseph Moreau described the treatment of the insane at the monastery at al-Khader, to the south-west of Bethlehem, a site noted by Goodrich-Freer too. Moreau emphasised the similarities between the treatment meted out by the Orthodox monks at al-Khader, and the ‘moral treatment’ advocated by the psychiatrist François Leuret, who had died in 1851. Both, in Moreau’s view, relied on a similar agent to prompt change and healing: fear.Footnote ¹⁰⁵

Leuret was widely discredited within French psychiatry, and so Moreau’s reference appears to have been a joke at his expense, pointing out the proximity between Leuret’s ‘moral treatment’ and the methods employed by monks in the Levant, rather than an attempt to take the latter more seriously by pointing out its resonances with respected French psychiatric practices. But taken together, this odd trio of commentators – Goodrich-Freer, Chaplin, and Moreau – blurs the boundaries between the medical and the non-medical treatment of the mentally ill.

Two of the sites noted by Goodrich-Freer appear to have been especially important to the miraculous treatment of the mentally ill in late Ottoman Palestine, both of them linked to al-Khidr, the ‘evergreen one’, a figure particularly revered by Sufis and identified with the Prophet Elijah by Jews and Muslims and with St George by Christians.Footnote ¹⁰⁷ The cave referenced by Goodrich-Freer is Elijah’s cave on Mount Carmel, Haifa, which she elsewhere described as being ‘resorted to by all classes, sects, and nationalities’ for its power.Footnote ¹⁰⁸ The other, as we have seen, was the monastery of St George in the village of al-Khader near Bethlehem. While far from the only important site for the healing of the insane in Palestine, the monastery at al-Khader attracted much comment, both before and after the First World War. In the 1920s, the Palestinian medical doctor and folklore researcher Tawfiq Canaan wrote about the monastery in his magnum opus, Mohammedan Saints and Sanctuaries in Palestine, and before that, in a series of articles for the journal of the Palestine Oriental Society, established in 1920 to promote archaeological, historical, and anthropological research in Palestine. Drawing on notes taken by his father about the monastery, Canaan described how the insane were restrained with chains in the belief that, once cured, St George himself would release them. While recounting the story told to his father by a priest, in which St George appeared to one of the sick as a gentle-looking man riding a horse and carrying a spear, Canaan himself gave a more sceptical account of how this ‘miraculous’ cure worked:

But the monastery, Canaan continued, had been renovated shortly before the outbreak of the war, and the treatment of the insane had improved significantly. A sanatorium had been built a short distance from the church, comprised of ‘good rooms’ with hygiene ‘in every respect better’, though the method of treatment remained fundamentally the same: each room came equipped with a chain that connected, either physically or symbolically, the ‘patient’ to the saint’s sanctuary so that miraculous cures could continue to be worked. In spite of these changes, Canaan confirmed what Feigenbaum also reported: that ‘[t]he present government has forbidden the acceptance of [the] insane in this place’.Footnote ¹¹⁰ Stephan Hanna Stephan, a civil servant in the new mandate government as well as an archaeologist, curator, and folklore researcher, also wrote about the monastery, reporting that under usual conditions an individual would be ‘healed’ in just a matter of weeks. But now, he noted, ‘this practice has ceased and the government has a lunatic asylum near Bethlehem which employs modern methods’.Footnote ¹¹¹

The termination of this practice was noted almost in passing in both Canaan and Stephan’s writings; indeed, reduced to a footnote in the former’s. It is difficult, moreover, to find references to the forbidding of this practice in the colonial archive either. Douglas Duff, stationed in Palestine from 1922, recounted in his memoirs that he had seen ‘some extraordinary cases where cures were effected’ at the monastery of St George near Bethlehem, so it may be that the ban on receiving the insane at al-Khader was not put in place until the middle of the 1920s, rather than immediately – or that it only gradually became effective.Footnote ¹¹² But it is not clear. While the case of the monastery at al-Khader would seem to follow the contours of the story outlined by Eugene Rogan, which we encountered earlier, of a European attempt since the late nineteenth century to wrest control over the mentally ill in the Levant from the hands of ‘men of religion’ to ‘men of science’,Footnote ¹¹³ the lacunae in the colonial archive around this story suggest a lack of real or sustained interest in this endeavour on the part of the mandate government. The government’s investment in psychiatry in Palestine was uneven: in spite of the department of health’s ambitious vision of the mental hospital as a site of cure rather than merely confinement, they were markedly less interested in drawing attention to their closure of alternatives or indeed evangelising about psychiatry to the population of Palestine. The picture we are left with, then, is not of a decisive or deliberate break with the past, but instead a period in which different modes of treatment appear to have coexisted, if uncertainly. This sense of ambiguity comes across most clearly in a list put together by Canaan in the mid-1920s of sanctuaries associated with al-Khidr: one site in Nablus was clearly no longer in use (‘Mentally diseased persons used to be fastened here with iron chains’); a second site in Nablus seems to have been still in use (‘The ill take a bath in this basin on Friday, believing that this will cure them’); and in a third, it was left unclear (‘There is a chain for the majanin’).Footnote ¹¹⁴

This sense of ambiguity only deepens when we shift our focus from sites to people. The mandate government certainly intervened to clamp down on those offering more alarming forms of non-medical treatment for mental illness. When a Lebanese man, Salim Abdu Harb, appeared in Jerusalem in the middle of the 1930s promising to cure the insane by branding a cross on their foreheads, he was arrested for practising as a doctor without a licence.Footnote ¹¹⁵ Yet exorcisms continued to be performed by other methods in the mandate period. The Dominican priest Antonin Jaussen wrote about one famed performer of such exorcisms, the Nabulsi shaykh Sa’ad al-Din, in 1923.Footnote ¹¹⁶ Jaussen had interviewed Sa’ad al-Din a number of times over the course of the year, and the shaykh explained how he healed the sick, particularly those whose sickness was a result of possession by jinn, by writing the names of Allah on paper as well as on the body of the possessed. While many came to him at Nablus, he also travelled to treat the sick: from Jaffa, where he cured one woman who had been sick for over three years, to the other bank of the Jordan, where he cured six people in and around Amman and Salt. His renown was such that before the war, the Ottoman authorities had reportedly brought the mentally ill to him to be treated. ‘The current government does not allow him the same liberty’, Jaussen noted dryly, but this did not seem to have dented his business. As he continued: ‘I met at his house a madman originally from a neighbouring village: he had been sent by the president of the municipality.’ Even as Jaussen sat with the shaykh, numerous people – men and women – approached him for help with various problems.Footnote ¹¹⁷

That the arrival of the mandate government did not mark a sharp break with ‘alternative’ approaches to the question of mental illness is clear; given the state’s limited resources and, indeed, apparent interest in this question, the enduring popularity of these forms of treatment into at least the interwar years should hardly come as a surprise. While it is possible to frame this as a failed or incomplete transposition of the question of mental illness from the domain of religion to science, it is not clear these terms would have necessarily been meaningful, or the line between them sharp, to those who actually sought help with mental illness in the late Ottoman and early mandate years. Just as some medical doctors attempted to rationalise the working of treatments at sacred sites, so too do the families of the mentally ill appear to have blurred the lines between medical and non-medical treatments across the region. Early reports from ʿAsfuriyyeh, for instance, emphasise how many of the patients arriving at the hospital bore signs of having suffered abusive treatment at the hands of men of religion before their admission.Footnote ¹¹⁸ But the reverse also happened. Just as many came to ʿAsfuriyyeh after failing to find relief at the hands of men of religion, those who consulted Sa’ad al-Din, for instance, sometimes turned to the shaykh after doctors failed them. Jaussen relates the story of one woman, Farizah, gravely ill for seven months, who had consulted all the doctors of Nablus before being brought to Sa’ad al-Din; the shaykh immediately recognised the work of the jinn and drove them out, healing her.Footnote ¹¹⁹ For the families of the sick, even if they distinguished between the methods used by mental hospitals and monasteries, doctors and shaykhs, this did not prevent them from shopping around for a cure for their relative’s mental ailments. Their options were seldom plotted out by a medicalised model of cure or confinement alone.

Even the ban imposed on accepting the insane at the monastery at al-Khader, which might look like a clear-cut case of state-sanctioned medical science supplanting popular religious practice, can be given a different reading when set alongside the government’s decision to establish the first government mental hospital near Bethlehem, within walking distance of the monastery. In many ways, the site made sense practically: the town was centrally located, just a twenty-minute journey by motor car from Jerusalem; it enjoyed a good water supply; the climate of Palestine’s hilly interior was judged superior to that of the coastal plain; and a handsome, spacious site was available.Footnote ¹²⁰ But it was certainly not the path of least resistance, as we saw. While part of the department of health’s determination to use this site in spite of opposition can be related to these practical considerations, and their ambitious vision of what this mental hospital should be like, it is nonetheless intriguing that the first government mental hospital was established just a mile or so from a site to which the insane had long been brought for treatment by Palestinians, a site that had – according to Canaan and others – just itself undergone a dramatic transformation to better accommodate the mentally ill. Was the department of health’s fixation on this site in part an attempt to feed off more established strategies for managing the mentally ill, to cannibalise rather than simply displace? This overlap in the geography of the medical and the sacred is not unique to Bethlehem or Palestine: in Lebanon, for instance, the Psychiatric Hospital of the Cross was established in 1937 on a hill outside Beirut known locally as ‘the possessed mount’, and already the home of a Capuchin convent.Footnote ¹²¹

While there is no explicit reflection on this overlap in the colonial archive, such striking proximity would have been difficult to overlook by those – patients as well as families – who made the journey to and from the hospital after 1922, as they retraced many of the same well-known steps that had been taken for generations by pilgrims seeking cure from al-Khidr. But in addition to geographic proximity, and routes to the hospital layered with other meanings and memories, there is a further way we might think of the overlap between the world of psychiatry and alternative worlds in which jinn are agentive and exorcisms effective, this time within the space of the hospital itself. As we have seen, to go to a mental hospital or consult a doctor did not necessarily require a disavowal of the supernatural; patients and their families might cycle between doctors and shaykhs, hospitals and shrines, all the while carrying their own understandings of their condition with them. Just as sacred caves were given medical rationalisations, so too should we consider how the space of the mental hospital could be invested with otherworldly meaning by those who occupied it. At the government mental hospital, like other contexts examined by medical anthropologists, patients who suspected their condition could be a result of the work of jinn, might ‘experience spectrality in medical encounters, as well as ambiguous cohabitations with human and jinni others’. Rather than a break with a superstitious past, as Feigenbaum and others might have it, we may think of mental hospitals as a haunted space; ‘not as rational, modern, and future-oriented institutions, but as multidimensional and multi-temporal spaces in which other worlds and neglected histories push through and demand attention’.Footnote ¹²² Patients whose bonds to the jinn had, as anthropologist Stefania Pandolfo evocatively puts it, ‘encysted’ – forming ‘an otherness that has become an unrescindable part of [the] self’Footnote ¹²³ – transformed the space of the hospital. But this commingling of the medical and the otherworldly may have drawn strength from other, more surprising sources: in particular, the use made by doctors, nurses, and other hospital staff of the term majnun,Footnote ¹²⁴ a term for the mad etymologically inseparable from its connection to the jinn.

The establishment of the first government mental hospital in 1922, far from being the first encounter between Palestine and modern psychiatry, sat instead at the interstices of a much more complex set of interactions: between the new British regime and its multiple Ottoman inheritances; between the department of health, other branches of government, and international humanitarian organisations; and between psychiatric modes of treatment and alternatives, diversely understood. These shaped the government mental hospital and the approach of the department of health more broadly, in numerous ways, from the urgency that surrounded the hospital’s opening, to its siting and how its purpose was defined and articulated. In the final part of this chapter, we turn our focus inwards, for a sense of what this institution would have been like across its first decade of operation, and for the start of a sense too of the staff and patients whose lives hinged, in one way or another, on the first government mental hospital at Bethlehem.

Staff and Patients at the First Government Mental Hospital

What would it have been like to live and work at the first government mental hospital in the 1920s? Over the first year or so, and indeed at intervals beyond that, it would have felt like a construction site: the amount of work needed to convert it was substantial and ongoing when the first patients were admitted towards the end of 1922, and across the decade further work and extensions would have meant more disruption. Indeed such was the unfinished state of the hospital when it opened that initially only male patients could be admitted, with work finished on a separate wing for female patients only in July 1923.Footnote ¹²⁵ In the meantime, patients remained at the Ezrath Nashim home, with the subsidy to the institution even increased in April 1923.Footnote ¹²⁶ It was not only the physical fabric of the hospital, from security to sanitation, being refigured in these early years. Both the staffing and the patient population of the hospital were in flux across these years, with two major developments: the appointment, in 1925, of Dr Mikhail Shedid Malouf as medical officer in charge of the hospital; and a gradual shift in patient demographics as increasing numbers of Jewish patients were admitted to the hospital.

When the government mental hospital first opened, it was run by a British matron, heading a staff that consisted of six nurses, six tamurgis – that is, medical orderlies – and ten servants.Footnote ¹²⁷ But the staff appeared to struggle, with the matron described as ‘having a very difficult task with the semi-trained staff at her disposal’Footnote ¹²⁸ in these years. In the face of these teething problems, the department of health looked to the colonial medical service in Egypt, and in particular the director of the Khanka asylum, Dr H. W. Dudgeon, for guidance. This is unsurprising: George Heron, the director of health, had served in the public health department of Egypt for nearly a decade before joining the Egyptian expeditionary force in the First World War and making his way to Palestine. As well as being asked for advice about the lock-and-key system to be used in the new mental hospital,Footnote ¹²⁹ colonial medical authorities in Egypt were approached in the hope of bringing experienced staff from the asylums at ʿAbbasiyya and Khanka to work in Palestine;Footnote ¹³⁰ when this plan fell through, staff at Bethlehem were sent to Egypt to receive training as mental hospital attendants.Footnote ¹³¹ But there was a particular problem finding suitable senior staff for the hospital, either from Palestine or Egypt. The issue, at least as Dudgeon saw it, was the fact the hospital was headed by a matron: ‘none of my men have been trained to petticoat government and the East resents it’.Footnote ¹³² The Palestine department of health appears to have accepted this assessment, and appointed a medical officer to take charge of the government mental hospital, with the British matron subordinated to him. Initially, this position was occupied by the Armenian physician Dr Khatcher H. Kesheshian, but he was moved into schools and prisons by 1925,Footnote ¹³³ and in November 1925, Dr Mikhail Shedid Malouf was placed in charge of the hospital.Footnote ¹³⁴ He would remain in post right up until the very eve of the end of the mandate.

Malouf is thus a central figure in the history of psychiatry in British mandate Palestine, and indeed this book, and a brief detour is more than justified for his biography. Malouf had not been born in what became mandate Palestine, but rather in Kfar ʿAqab in Mount Lebanon in 1894. This seems to have mattered: early reports on the department of health within the Arabic-language press in Palestine referred to him as being Syrian, by contradistinction to European and Palestinian employees, in a breakdown of the department’s demographics in 1924.Footnote ¹³⁵ And when he took leave, it seems he returned to Lebanon.Footnote ¹³⁶ But it is important to remember that Malouf and his Palestinian colleagues would nonetheless have had much in common, not least their education. Malouf studied medicine at the Syrian Protestant College – as the American University of Beirut was then known – graduating in 1916 and continuing on to the Imperial Medical School in Istanbul.Footnote ¹³⁷ This was a typical itinerary for university-trained Palestinian medical doctors too.Footnote ¹³⁸ While Michael Provence has noted how shared education, experiences, and social worlds knitted together a last Ottoman generation of military and political leaders across the fragmented region in the mandate era,Footnote ¹³⁹ many of the doctors employed by the health department in British mandate Palestine represented another layer to the last Ottoman generation – one which shared not only an education and profession but, as members of an emergent late Ottoman middle class, consumption habits, aesthetic preferences, and social mores too.Footnote ¹⁴⁰ Though it is difficult to get much sense of Malouf’s social or personal life,Footnote ¹⁴¹ the magazine of the American University of Beirut’s alumni association, al-Kulliyah, reveals that at least until the mid-1930s he was assiduous in keeping up links with his alma mater, informing them of career developments like his appointment to the Bethlehem mental hospital, regularly returning to visit and attend commencement exercises while spending his annual leave in Lebanon, and making the occasional financial contribution too.Footnote ¹⁴² These links, forged in the late Ottoman period, appear to have mattered more to him than any sense of solidarity with colleagues in Palestine; it is notable, for instance, that he seems to have remained aloof from attempts to organise professionally which culminated in the establishment of the Palestine Arab Medical Association in the 1940s.

In spite of his appointment to take charge of the Bethlehem mental hospital, before 1925 Malouf does not appear to have had any special training or indeed interest in psychiatry. While by the early 1920s, medical students at the American University of Beirut could take a course of lectures and clinical demonstrations on mental diseases at ʿAsfuriyyeh as part of their final year of studies,Footnote ¹⁴³ the same opportunity would not have been available to Malouf in the previous decade. When he was first employed by the newly created department of health in 1920,Footnote ¹⁴⁴ his focus seems to have been quite different. In those early years, he was assigned to Hebron as the medical officer at a travelling ophthalmic hospital; he even went to Egypt for a special course on ophthalmology.Footnote ¹⁴⁵ His appointment to the government mental hospital in 1925, then, marked a dramatic change of direction in his career. While he was no specialist, reports made on Malouf’s work leave no doubt about his competence: he was routinely described as capable, efficient, and good at organisation.Footnote ¹⁴⁶ And he appears to have learnt on the job: the director of health described him as having special aptitude in the field of mental disease in 1931, with ‘a fair knowledge of psychopathic medicine’.Footnote ¹⁴⁷ He would continue, as we will see in later chapters, to cultivate this expertise, particularly in the 1940s around war-related trauma and new psychiatric treatments.Footnote ¹⁴⁸

Malouf’s appointment did not resolve all staffing issues at the hospital, however. While an early area of concern had been training male attendants, recruiting female nursing staff proved to be a more persistent problem. Twelve training centres for nurses had been established in Palestine in the 1920s,Footnote ¹⁴⁹ and in 1928, the department of health boasted that Palestinian Arab women were considered to ‘make capable and reliable nurses and a demand for them has arisen in neighbouring countries’, such that ‘Palestine has supplied nurses to Egypt, Syria, Transjordan, Turkey, and Iraq’. But at the same time, the department conceded there was ‘difficulty in inducing Moslem women of good family to enter the nursing profession’.Footnote ¹⁵⁰ Decades later, this remained a problem: a 1946 report noted the ‘[r]ecruitment of Arab girls to the nursing profession is most inadequate, and the staffing of hospitals in wholly Arab areas is always a difficult problem’.Footnote ¹⁵¹ The government mental hospital in particular had a reputational problem as a result of certain scandals that occurred in the 1920s: in 1926, the British matron of the hospital, Miss D. L. Whitaker, locked an Arab nurse in an isolation cell reserved for maniacal patients after an argument. Whitaker was swiftly fired,Footnote ¹⁵² but Heron lamented that ‘[t]he incident at the Bethlehem mental hospital is known throughout the hospitals of the country and has already severely shaken the confidence of the Palestinian nurses of the service in the attitude of the British members of the department of health towards them’.Footnote ¹⁵³

Not only the staffing but the patient population underwent changes over the course of the 1920s. Initially, the department of health planned to admit only non-Jewish patients to the mental hospital at Bethlehem. The Jewish mentally ill would continue to be treated at the Ezrath Nashim home, and the government would provide a reduced subsidy to cover the upkeep of ten indigent, non-paying patients at this institution. The rationale given for this policy is striking. ‘It is not possible to provide separated accommodation at the government asylum for the insane for Jews’, Heron explained in May 1923, ‘and the Moslem and Jewish lunatics cannot be mixed.’Footnote ¹⁵⁴ If the case of the Ezrath Nashim’s treatment of Muslim, Christian, and Jewish patients earlier in the 1920s might not have represented, to Heron, a compelling counterexample of ‘Moslem and Jewish lunatics’ being successfully mixed, Heron’s view was also at odds with the avowedly non-sectarian attitude adopted at ʿAsfuriyyeh, an institution which was widely admired by British officials across the region. Heron here may have been guided by the example of colonial India, where religion had come to displace caste as the organising category of colonial rule in the early twentieth century; he would not have been the only mandate official to look to colonial India for a template of British rule in Palestine.Footnote ¹⁵⁵ But although religion became increasingly important in Indian mental hospitals in the interwar years,Footnote ¹⁵⁶ Heron’s declaration that ‘Moslem and Jewish lunatics’ could not be mixed would not have found direct parallels even in India.

Heron’s conviction was an unusual one, and one that began to break down quickly. Rather than subsidise the Ezrath Nashim home to accommodate indigent non-paying Jewish patients, just a few months later Heron had reconsidered. ‘As an economy’, he proposed to transfer those ten indigent patients to the government mental hospital at Bethlehem. While this would entail hiring additional staff, including ‘a Jewish cook’ – that is, a cook who could prepare food for observant Jewish patients – Heron estimated that this would ultimately result in savings to the government.Footnote ¹⁵⁷ In November 1923, plans were in motion for the establishment of a kosher kitchen, complete with specially marked cutlery and other utensils.Footnote ¹⁵⁸ Indeed, if Heron’s position that Muslim and Jewish patients could only be mixed with difficulty had any basis in pragmatics, it may have been the need to make separate arrangements for food that made him hesitate. But whatever the case, by 1925 the government mental hospital was admitting equal numbers of Muslim, Christian, and Jewish patients.Footnote ¹⁵⁹ The department of health’s annual report from the following year made clear the scale of the shift: ‘[t]he original arrangement by which Jewish lunatics were to be treated in the Ezrath Nashim home and other patients in the Government Mental Hospital, could not be maintained and about one third of the patients under treatment at Bethlehem were Jewish cases’.Footnote ¹⁶⁰

As patient demographics underwent this dramatic shift over the course of the 1920s, what would it have been like to be admitted to this institution? What can we recover of the routines and sensations of everyday life in the government mental hospital? To begin to develop a sense of this, it is necessary to weave together fragmentary but often evocative references in the colonial archive. The journey to the hospital would have been a bumpy, uncomfortable one, we know, as a starting point for imagining patient experiences of this institution. In 1931, and presumably before as well, the approach road to the hospital was described as being ‘in an extremely bad state of disrepair’; there were ‘large rocks sticking up in the middle of the road’, and ‘numerous and deep pot-holes, which in the winter, when full of water, will make it really dangerous for anyone using the road with a motor car’.Footnote ¹⁶¹ Once they were off this bumpy road and in the hospital itself, a patient was supposed to be photographed. In practice, because this involved hiring a private photographer, and the photographer refused to make the journey unless there were more than six patients to be photographed, it may have been a while before any photograph could be taken and attached to a patient’s case file.Footnote ¹⁶² A patient would also be administered a Wassermann test on arrival, to check for syphilis; patients from Jaffa and its surroundings were additionally examined for bilharzia, a parasitic infection thought common to the area.Footnote ¹⁶³ Subjected to these tests and greeted by nurses wearing blue cotton uniforms emblazoned with the letters G.H.S. – Government Hospital Service – a patient’s first impression of this institution may well have been dominated by the sense of this as a medicalised, professionalised space.Footnote ¹⁶⁴

After admission, how would patients – assuming they were not seriously ill, or confined to one of the multiple isolation cellsFootnote ¹⁶⁵ – have passed their days in the government mental hospital? Although unsurprising in view of the fact that the hospital was set in a site of 5 acres, it is still striking that patients were reported to ‘spend practically the whole day in the hospital grounds except during the four winter months’, when snow could blanket Bethlehem and its surroundings. Outdoors, they were employed in a range of activities: ‘gardening, vegetable growing, poultry and rabbit-keeping, carpentry and building’.Footnote ¹⁶⁶ This had been envisaged even as early as the planning of the initial repairs to the site. When repairs were ordered on the cistern which supplied the hospital building itself, for instance, an unfinished cistern was discovered in the garden; orders were given ‘to repair [it] and fix pump to store water for gardening purposes’.Footnote ¹⁶⁷ A shelter to protect male patients from the elements, particularly the sun, while out of doors was also one of the early improvements ordered;Footnote ¹⁶⁸ later on, better garden seats were requested for the patients’ enjoyment of the hospital grounds, as was a gramophone ‘for the patients’.Footnote ¹⁶⁹ In addition to gardening, efforts were made to instruct patients in other forms of employment. In November 1924, Heron proposed installing two looms at the hospital, and asked for the instructor from the government prison at Jerusalem to be sent to the hospital to teach certain selected patients how to use them.Footnote ¹⁷⁰ Employment, particularly gardening, was understood as having therapeutic value, but it shaped how patients sensorily experienced the hospital too. Those vegetables, egg-laying chickens, and rabbits tended within the hospital grounds ‘make a useful supplement to the patients’ ordinary diet’, as the department’s annual report put it in 1929.Footnote ¹⁷¹ The noises of the animals, and the sound of work in the gardens and elsewhere, would also have contributed to the hospital’s soundscape, competing with the music playing on the gramophone.

But the fact the patients spent so much of the year outside had the additional benefit of easing the sense of overcrowding at an institution, which was, already within a few years of opening, desperately full. Even in 1925, lack of space at the hospital meant ‘many insane persons have had to be detained in police lock-ups and other unsuitable places while awaiting admission’.Footnote ¹⁷² By 1926, the strain on the institution was such that a dining room had to be converted into a dormitory to accommodate ten additional patients, and Dr Malouf was urgently requesting the construction of two pavilions to make up for the loss of dining and other recreational spaces within the hospital. While the loss of these spaces was not, in summer, a particularly serious issue, ‘[i]t is getting dark early these days’, Malouf wrote in September, ‘and very soon the patients will not be able to have their suppers outside, nor can they have it inside’.Footnote ¹⁷³ By 1929, the average number of patients at the hospital – which had had a bedstrength of fifty in 1925 – surpassed sixty;Footnote ¹⁷⁴ by 1930, more than eighty acute cases were awaiting admission.Footnote ¹⁷⁵

The pavilions requested by Malouf as an urgency in 1926 were only constructed in summer 1931, however.Footnote ¹⁷⁶ In the intervening years, the department of health had committed itself to a plan to construct a new government mental hospital from scratch, with a site secured and further work to the first government mental hospital – which was still, after all, only leased from the Jerusalem Verein rather than owned outright by the government – put on hold.Footnote ¹⁷⁷ But this plan to construct a new mental hospital was torpedoed by the onset of the global depression, and the swingeing cuts inflicted on the mandate’s budgets across the board in 1931.Footnote ¹⁷⁸ Failure to deliver on this proposed institution left the government open to criticism from the Jewish Agency, the new quasi-governing organisation representing all Jews in Palestine, which lamented that in abandoning their plan the government had ‘done away with the hopes of a radical solution of the problem of the insane’.Footnote ¹⁷⁹ But it also meant that the lease of the existing government mental hospital site could be renewed, securing the site for a further five years, and much-needed work finally done to improve it.Footnote ¹⁸⁰

Against this backdrop of severe overcrowding and seemingly endless delays to renovation and extension work, it is unsurprising Palestinians continued to seek out many of the same options for the treatment of mentally ill relatives as they had done in the late Ottoman period. In 1930, to give a representative snapshot, twenty patients were admitted to the government mental hospital; thirty-two were admitted to the Ezrath Nashim home, and six to ʿAsfuriyyeh, that same year.Footnote ¹⁸¹ At the start of the 1920s, the department of health had articulated an ambitious vision of the proposed mental hospital at Bethlehem in response to critics and sceptics both within and outside the new British administration. Feigenbaum, for one, bought into this as marking a sea-change in beliefs and practices around mental illness in Palestine. Not only, as we have seen across this chapter, was the reality more complex, as the department of health negotiated with late Ottoman institutions, a range of critics, and non-medical alternatives, but within a decade, the veneer of ambition that characterised the department’s initial foray into this area of healthcare had been worn down – even as the urgency of dealing with a scandalous lack of provision for the mentally ill continued to grow unabated. Long-delayed pavilions on a leased site: this was increasingly recognised as an inadequate solution to the problem of overcrowding by the early 1930s. And the scale of that overcrowding, the scale of the government’s failure to make adequate provision for the mentally ill, was about to become known in a more systematic way than it ever had been before, or indeed would be again, when in November 1931, a census was taken of the population of Palestine – and a return of the ‘insane’ population made. It is to that enumeration of the insane that we now turn.