The Gory History of Barber Surgeons: Medieval Medicine Gone Mad

The Gory History of Barber Surgeons: Medieval Medicine Gone Mad

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It’s no surprise that the history of medicine had a rocky and somewhat gruesome journey before reaching its current, modern state. From the earliest meddling in surgery in Classical Antiquity to the Middle Ages and a much more brutal and crude way of dealing with illness and injury, medicine wasn’t always so beneficial. And this fact becomes clearer when we consider the role of barber surgeons.

Barber surgeons were the usual medical practitioners through much of the Middle Ages, tasked with everything from bloodletting, amputation, leeching, pulling teeth, and, of course, the everyday duties of cutting beards and hair. It sounds efficient, right? While you get your arm sawed off, you can get a haircut too. But it certainly wasn’t pleasant to be afflicted in the Middle Ages.

From Haircuts to Amputations – How Barber Surgeons Emerged

From as early as 1000 AD, the role of surgeons and physicians was curiously separated. The surgeons were often catering to the lower class, while physicians resided in courts and castles. The latter only observed the afflicted – they considered themselves above the practice of surgery, and instead observed the patients.

Physicians would spot the symptoms, injuries, and afflictions, and offer their counsel accordingly - relying on their academic knowledge to suggest the course of treatment. They would also be found almost exclusively in the service of the wealthy , where they would treat the royal and aristocratic families and their knowledge was held in high regard. These physicians studied in Latin and fluently spoke it, they were considered highly educated, and as such, the practice of surgery was considered beneath their dignity.

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But what of the other classes? The soldiers, peasants, monks and workers? In their lives, injuries and afflictions were commonplace, more so than with the nobles. And as the physicians were loath to get their hands dirty, someone had to – the barber surgeons .

‘The Surgeon’ by David Teniers the Younger, 1670s.

While the physicians, mostly in the 15th century and onwards, were accredited and licensed by the universities in which they studied, barber surgeons on the other hand, were not. They had to apply to the trade guild and would subsequently become apprentices to barbers. This apprenticeship was often difficult, rough, and mixed up – it covered a range of services, although it was connected with barbers.

Over time the term barber surgeon was born –and the basic service of a barber gained many other tasks.

An average surgeon that was trained in one of these guilds was tasked with a variety of “healing” tasks that physicians wouldn’t do. The surgeon was expected to deal with basic wounds and lacerations, with burns and skin rashes, setting fractured bones and dislocated limbs, venereal diseases, lancing infections, topical applications, and applications of poultices. The more skilled surgeons would also perform demanding procedures including trepanation, amputation, cauterization, and delivering babies.

Ambroise Paré, as an apprentice barber-surgeon in a busy shop in Paris. Wood engraving by E. Morin after J. Ansseau. (Wellcome Images/ CC BY 4.0 )

And the barber surgeon arose as a more lowly form of a true surgeon –essentially an apprentice. They were tasked with more basic procedures, and tasks that were slightly more gruesome and dirty. Besides fetching and assisting, a barber surgeon would deal with bloodletting, leeching, cupping, and pulling out teeth . As time progressed, barber surgeons – the apprentices –became increasingly independent, and eventually became competition for proper surgeons.

The earliest and most basic roles of barber surgeons were connected to monasteries. Even as early as 1000 AD they would be employed, through guilds, by the numerous monasteries around Europe. The main reason for this was actually because of their barbering skills. They were on-hand to cut the monks’ hair regularly, as they needed to be tonsured. Tonsuring is the religious practice of shaving the top of the head.

St Bartholomew (1473) by Carlo Crivelli.

But in time, the barbers were allowed to do more than just cut hair in the monasteries. In fact, cutting hair was done in their spare time. As monasteries took on the role of hospitals and sanctuaries, especially in France and Germany of the Middle Ages, barber surgeons took a real medical role. Hair cutting went on to bloodletting, and bloodletting to setting limbs, and eventually came amputation and everything in between.

When a law was passed in 13th century France which required all physicians in training to swear an oath not to perform surgery, it effectively paved the way for barbers to take up the vacant space, often learning as they went. Which didn’t bode well for the poor and soldiers.

A barber surgeon’s bloodletting set, beginning of 19th century, Märkisches Museum Berlin. (Anagoria/ CC BY 3.0 )

Leeches, Limbs, and Loose Teeth

With the rise of urban areas – towns and villages – the need for medical assistance grew. And soon physicians were outnumbered by surgeons. They had the learning, but surgeons had the hands-on approach.

To protest the physicians and their restriction of practicing surgery, a special college was created in 1210 at St. Côme. It was established and run by Jean Pittard and was the first step towards the later emergence of the guilds. The surgeons at St. Côme were separated into two classes – the long and short robes. The long robes were the proper, established master surgeons, while the short robes were the apprentices –the barbers in training.

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Anatomical Theater of the Paris Academy of Surgery in 1694.

By 1371 in France, barber surgeons paradoxically surpassed master surgeons. This happened because physicians saw the rising influence of master surgeons and tried to stifle it by once again giving headway to those who were less-educated. And so in 1371 the French king proclaimed his own barber as the head of all barbers and surgeons of France.

And about seven decades before that, in 1308, King Edward II of England granted the barbers guild status and they played a major role in Britain of the time. Afterwards, in 1375, this guild was further established and separated into two distinct roles – those who did surgery and those who were only barbers.

A proclamation was also made that required all surgeons to be licensed by the Crown in order to perform their services. And in Glasgow, under James the VI, all apothecaries, surgeons, barbers, and barber surgeons were united under one charter - but they were dominated by the majority of barber surgeons.

The role of barber surgeons became increasingly associated with more gruesome surgical procedures when their services were employed in wars. They were prominent when Henry V undertook his campaign in France in 1415, as well in the Thirty Years’ War from 1618 and 1648. Wars would bring a lot of work for budding barber surgeons, when they were on-hand to amputate, suture, stitch, and cauterize. But in peace time, these gruesome tasks were performed rarely, and so, in order to earn a living, the barber surgeons would shift to their barber role, cutting hair for a living.

When their services were needed, they were indeed many and very…colorful. A barber surgeon’s roles were diverse and in time they gained more importance than simply crude pseudo-medicine. One standard concept of their practice was the so-called humorism.

Alchemic approach to four humors in relation to the four elements and zodiacal signs.

This system of medicine survived from Roman and Greek medicinal practices and revolved around four “chemical systems” that regulated human behavior and health. These four temperaments were: sanguine, choleric, melancholic, and phlegmatic. Barber surgeons continued the practice in the Middle Ages.

They would almost always examine the patient’s urine in order to determine their affliction via a chart. Based on the color, consistency, and the taste of the patient’s urine, the barber surgeon would proceed with treatment. One of the most common “remedies” was bloodletting. It was believed that through removal of blood, the surgeon would also remove the bad “humors” from the body.

A Medieval urine wheel. ( OnlineRover)

In the early medieval period, this practice was usually performed with leeches. In fact, this was such a popular method that it nearly drove leeches to extinction. As methods evolved further, barber surgeons used a specialized tool that helped them open an incision in the patient’s vein and carefully extract up to a pint of blood from a person.

Bloodletting was a common procedure and remained in heavy use all the way up to the 18th and 19th centuries. But the truth is that only on rare occasions would it be beneficial. And a beneficial effect was only a temporary feeling, as the loss of blood would reduce blood pressure. In fact, bloodletting was usually harmful to patients.

Amputation, Trepanation, and No Anesthetization

Amputations were another common procedure that barber surgeons performed, and with highest frequency in war. The procedure was disliked by the patients, for obvious reasons, but mostly because of the lack of anesthetics.

The same went for the procedure of trepanation, which was also quite common. It constitutes a hole being bored into the skull of the patient, exposing the outermost layer of the protective membrane of the brain and the central nervous system. It was believed that drilling the hole would alleviate different ailments and release pressure. It was considered a cure for seizures, skull fractures, and different behavioral problems. Early on it was believed that drilling a hole in the skull would allow demons and evil forces to escape.

‘The Extraction of the Stone of Madness’ (The Cure of Folly) by Hieronymous Bosch.

The Decline of the Barber Surgeons

As time went on and surgery gained a more refined and important aspect, barber surgeons quickly became phased out. This was directly caused by surgery shifting from a craft to a profession. One of the first steps towards the diminishing of barber surgeons occurred in France, when surgery got a boost under the rule of Louis XIV .

His grandson, Louis XV, would further this when he established five chairs of surgery at the college of St. And finally, in 1743, every barber and wig maker in France was forbidden to perform surgery. Two years later, barbers and surgeons were completely separated in England as well.

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A barber-surgeon extracting stones from a woman's head; symbolizing the expulsion of 'folly'(insanity). Watercolor by J. Cats, 1787, after B. Maton. (Wellcome Images/ CC BY 4.0 )

When we take the early medicinal and surgical practices into account, we can easily cherish what we have today. It is clear that the dated Roman and Greek practices were awfully misplaced in Medieval times and medicine suffered from stagnation. But the ones who suffered the most were the patients –the afflicted who were completely clueless about the workings of their bodies. Pain was a part of life for them, and the barber surgeons were considered healers, but they generally weren’t.

It also gives us an insight into the class divide of our past, when the nobility and the poor were hugely separated. But when it came to surgical procedures, this divide was partly erased because when the barber surgeon whipped out his trepanning drill or his trusty amputation saw, all men were seen as one – just flesh and blood.

Agents of Metabolism

The Four Humors are the metabolic agents of the Four Elements in the human body. The right balance and purity of them is essential to maintaining health. The Four Humors and the elements they serve are as follows:
All four of these humors, or vital fluids, are present in the bloodstream in varying quantities:
Blood, or the Sanguine humor, is the red, hemoglobin-rich portion.
Phlegm, or the Phlegmatic humor, is present as the clear plasma portion.
Yellow Bile, or the Choleric humor, is present as a slight residue or bilirubin, imparting a slight yellowish tint.
Black Bile, or the Melancholic humor, is present as a brownish grey sediment with platelets and clotting factors.

10 Children's Soothing Syrups

In the 19th century, people were simply too busy churning butter, waxing their moustaches or changing in and out of 15 layers of undergarments every time they went to take a piss to be bothered with disobedient children. To aide the stressed 19th-century mother, a series of "soothing syrups," lozenges and powders were created, all which were carefully formulated to ensure they were safe for use by those most vulnerable members of the family. Oh, no, wait. Actually, they pumped each bottle full of as many narcotics as it could hold.

For instance, each ounce of Mrs. Winslow's Soothing Syrup contained 65 mg of pure morphine.

Based on our experiences teething and experimenting with pure morphine, that seems like a lot. Finally in 1910 the New York Times decided the whole narcotic-babysitter concept was probably bad in the long run, and ran an article pointing out that these soothing syrups contained, ". morphin sulphate, chloroform, morphine hydrochloride, codeine, heroin, powdered opium, cannabis indica," and sometimes several of them in combination.

You can't say the soothing syrups weren't effective, as long as you didn't mind your toddler being strung out on the midnight oil or, you know, dead. That's right, the terrible 2s weren't just a cutesy euphemism back then. Kids were not only at their brattiest but also often died, in many cases after their parents tried to cure the aforementioned brattiness with narcotic concoctions that would give Lindsay Lohan a nose bleed.

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Here's What Sex Toys Have Looked Like Throughout History

It can be unsettling thinking about your grandmother or grandfather having sex or, heaven forbid, using a vibrator. But your ancestors (well, maybe not yours specifically, but someone's ancestors) definitely used sex toys.

Granted, their sex toys weren't made from the finest purple silicone, but they still got the job done. And isn't that all that really matters? Here's a brief look at sex toys throughout history &mdash from the bizarre and hilarious to the straight-up genius.

This bronze dildo with a ring attached to it (perhaps to be worn as a strap-on?) was found inside the tomb of an aristocrat in the Chinese city of Yizheng in the Jiangsu province . Judging by the materials and intricate details used when creating this relic, the ancient Chinese considered sex toys an art form.

This jade and bronze butt plug was discovered in the tomb of a king near modern-day Shanghai. Researchers believe the butt plugs were actually used to seal certain orifices in corpses a nd to maintain the body' s chi (the life force and energy found in the body) , not as sex toys. But this one could certainly pass as a prototype for today's toys.

If you were a horny woman or man living in Ancient Greece, you probably didn't have a slew of sex shops downtown, but you did have plenty of bread &mdash which could be fashioned into a perfect bread dildo. Folks living back in those days reportedly didn't identify as heterosexual, homosexual, or bisexual &mdash they just indulged whatever pleasure they fancied. Bread dildos were used by men and women as a sexual aid, according to Vicki Leon, author of The Joy of Sexus: Lust, Love & Longing in the Ancient World &mdash a biodegradable sexual aid, which made them responsible sexy people.

The steam-powered Manipulator is known as the first hand-crank vibrator ever created &mdash years before electricity would truly change the game. American physician George Taylor came up with this unique, utterly frightening design, which consists of a dildo attached to a steam engine that produced vibrations. You've got to give credit where it's due: Unlike many vibrators that would come after this one, there's no way you can pass this off as a beauty tool &mdash it was honest about its intentions to produce bodily stimulation. It's important to remember that a device like this one wasn't created with female orgasm in mind &mdash the goal back in those days was to help alleviate hysteria in women &mdash and, by "hysteria," they meant sexual frustration, but it would be decades before those actual words would be used.


Although there is little record to establish when plants were first used for medicinal purposes (herbalism), the use of plants as healing agents, as well as clays and soils is ancient. Over time, through emulation of the behavior of fauna, a medicinal knowledge base developed and passed between generations. Even earlier, Neanderthals may have engaged in medical practices. [1] As tribal culture specialized specific castes, shamans and apothecaries fulfilled the role of healer. [2] The first known dentistry dates to c. 7000 BC in Baluchistan where Neolithic dentists used flint-tipped drills and bowstrings. [3] The first known trepanning operation was carried out c. 5000 BC in Ensisheim, France. [4] A possible amputation was carried out c. 4,900 BC in Buthiers-Bulancourt, France. [5]

Mesopotamia Edit

The ancient Mesopotamians had no distinction between "rational science" and magic. [8] [9] [10] When a person became ill, doctors would prescribe both magical formulas to be recited as well as medicinal treatments. [8] [9] [10] [7] The earliest medical prescriptions appear in Sumerian during the Third Dynasty of Ur (c. 2112 BC – c. 2004 BC). [11] The oldest Babylonian texts on medicine date back to the Old Babylonian period in the first half of the 2nd millennium BCE. [12] The most extensive Babylonian medical text, however, is the Diagnostic Handbook written by the ummânū, or chief scholar, Esagil-kin-apli of Borsippa, [13] [14] during the reign of the Babylonian king Adad-apla-iddina (1069–1046 BCE). [15] Along with the Egyptians, the Babylonians introduced the practice of diagnosis, prognosis, physical examination, and remedies. In addition, the Diagnostic Handbook introduced the methods of therapy and cause. The text contains a list of medical symptoms and often detailed empirical observations along with logical rules used in combining observed symptoms on the body of a patient with its diagnosis and prognosis. [16] The Diagnostic Handbook was based on a logical set of axioms and assumptions, including the modern view that through the examination and inspection of the symptoms of a patient, it is possible to determine the patient's disease, its cause and future development, and the chances of the patient's recovery. The symptoms and diseases of a patient were treated through therapeutic means such as bandages, herbs and creams. [13]

In East Semitic cultures, the main medicinal authority was a kind of exorcist-healer known as an āšipu. [8] [9] [10] The profession was generally passed down from father to son [8] and was held in extremely high regard. [8] Of less frequent recourse was another kind of healer known as an asu, who corresponds more closely to a modern physician [7] and treated physical symptoms using primarily folk remedies composed of various herbs, animal products, and minerals, as well as potions, enemas, and ointments or poultices. [7] These physicians, who could be either male or female, also dressed wounds, set limbs, and performed simple surgeries. [7] The ancient Mesopotamians also practiced prophylaxis [7] and took measures to prevent the spread of disease. [7]

Mental illnesses were well known in ancient Mesopotamia, [17] where diseases and mental disorders were believed to be caused by specific deities. [6] Because hands symbolized control over a person, mental illnesses were known as "hands" of certain deities. [6] One psychological illness was known as Qāt Ištar, meaning "Hand of Ishtar". [6] Others were known as "Hand of Shamash", "Hand of the Ghost", and "Hand of the God". [6] Descriptions of these illnesses, however, are so vague that it is usually impossible to determine which illnesses they correspond to in modern terminology. [6] Mesopotamian doctors kept detailed record of their patients' hallucinations and assigned spiritual meanings to them. [17] A patient who hallucinated that he was seeing a dog was predicted to die [17] whereas, if he saw a gazelle, he would recover. [17] The royal family of Elam was notorious for its members frequently suffering from insanity. [17] Erectile dysfunction was recognized as being rooted in psychological problems. [17]

Egypt Edit

Ancient Egypt developed a large, varied and fruitful medical tradition. Herodotus described the Egyptians as "the healthiest of all men, next to the Libyans", [18] because of the dry climate and the notable public health system that they possessed. According to him, "the practice of medicine is so specialized among them that each physician is a healer of one disease and no more." Although Egyptian medicine, to a considerable extent, dealt with the supernatural, [19] it eventually developed a practical use in the fields of anatomy, public health, and clinical diagnostics.

Medical information in the Edwin Smith Papyrus may date to a time as early as 3000 BC. [20] Imhotep in the 3rd dynasty is sometimes credited with being the founder of ancient Egyptian medicine and with being the original author of the Edwin Smith Papyrus, detailing cures, ailments and anatomical observations. The Edwin Smith Papyrus is regarded as a copy of several earlier works and was written c. 1600 BC. It is an ancient textbook on surgery almost completely devoid of magical thinking and describes in exquisite detail the examination, diagnosis, treatment, and prognosis of numerous ailments. [21]

The Kahun Gynaecological Papyrus [22] treats women's complaints, including problems with conception. Thirty four cases detailing diagnosis and [23] treatment survive, some of them fragmentarily. [24] Dating to 1800 BCE, it is the oldest surviving medical text of any kind.

Medical institutions, referred to as Houses of Life are known to have been established in ancient Egypt as early as 2200 BC. [25]

The Ebers Papyrus is the oldest written text mentioning enemas. Many medications were administered by enemas and one of the many types of medical specialists was an Iri, the Shepherd of the Anus. [26]

The earliest known physician is also credited to ancient Egypt: Hesy-Ra, "Chief of Dentists and Physicians" for King Djoser in the 27th century BCE. [27] Also, the earliest known woman physician, Peseshet, practiced in Ancient Egypt at the time of the 4th dynasty. Her title was "Lady Overseer of the Lady Physicians." [28]

India Edit

The Atharvaveda, a sacred text of Hinduism dating from the Early Iron Age, is one of the first Indian texts dealing with medicine. The Atharvaveda also contains prescriptions of herbs for various ailments. The use of herbs to treat ailments would later form a large part of Ayurveda.

Ayurveda, meaning the "complete knowledge for long life" is another medical system of India. Its two most famous texts belong to the schools of Charaka and Sushruta. The earliest foundations of Ayurveda were built on a synthesis of traditional herbal practices together with a massive addition of theoretical conceptualizations, new nosologies and new therapies dating from about 600 BCE onwards, and coming out of the communities of thinkers which included the Buddha and others. [29]

According to the compendium of Charaka, the Charakasamhitā, health and disease are not predetermined and life may be prolonged by human effort. The compendium of Suśruta, the Suśrutasamhitā defines the purpose of medicine to cure the diseases of the sick, protect the healthy, and to prolong life. Both these ancient compendia include details of the examination, diagnosis, treatment, and prognosis of numerous ailments. The Suśrutasamhitā is notable for describing procedures on various forms of surgery, including rhinoplasty, the repair of torn ear lobes, perineal lithotomy, cataract surgery, and several other excisions and other surgical procedures. Most remarkable was Susruta's surgery specially the rhinoplasty for which he is called father of modern plastic surgery. Susruta also described more than 125 surgical instruments in detail. Also remarkable is Sushruta's penchant for scientific classification: His medical treatise consists of 184 chapters, 1,120 conditions are listed, including injuries and illnesses relating to aging and mental illness.

The Ayurvedic classics mention eight branches of medicine: kāyācikitsā (internal medicine), śalyacikitsā (surgery including anatomy), śālākyacikitsā (eye, ear, nose, and throat diseases), kaumārabhṛtya (pediatrics with obstetrics and gynaecology), bhūtavidyā (spirit and psychiatric medicine), agada tantra (toxicology with treatments of stings and bites), rasāyana (science of rejuvenation), and vājīkaraṇa (aphrodisiac and fertility). Apart from learning these, the student of Āyurveda was expected to know ten arts that were indispensable in the preparation and application of his medicines: distillation, operative skills, cooking, horticulture, metallurgy, sugar manufacture, pharmacy, analysis and separation of minerals, compounding of metals, and preparation of alkalis. The teaching of various subjects was done during the instruction of relevant clinical subjects. For example, the teaching of anatomy was a part of the teaching of surgery, embryology was a part of training in pediatrics and obstetrics, and the knowledge of physiology and pathology was interwoven in the teaching of all the clinical disciplines. The normal length of the student's training appears to have been seven years. But the physician was to continue to learn. [30]

As an alternative form of medicine in India, Unani medicine found deep roots and royal patronage during medieval times. It progressed during the Indian sultanate and mughal periods. Unani medicine is very close to Ayurveda. Both are based on the theory of the presence of the elements (in Unani, they are considered to be fire, water, earth, and air) in the human body. According to followers of Unani medicine, these elements are present in different fluids and their balance leads to health and their imbalance leads to illness. [31]

By the 18th century CE, Sanskrit medical wisdom still dominated. Muslim rulers built large hospitals in 1595 in Hyderabad, and in Delhi in 1719, and numerous commentaries on ancient texts were written. [32]

China Edit

China also developed a large body of traditional medicine. Much of the philosophy of traditional Chinese medicine derived from empirical observations of disease and illness by Taoist physicians and reflects the classical Chinese belief that individual human experiences express causative principles effective in the environment at all scales. These causative principles, whether material, essential, or mystical, correlate as the expression of the natural order of the universe.

The foundational text of Chinese medicine is the Huangdi neijing, (or Yellow Emperor's Inner Canon), written 5th century to 3rd century BCE. [33] Near the end of the 2nd century CE, during the Han dynasty, Zhang Zhongjing, wrote a Treatise on Cold Damage, which contains the earliest known reference to the Neijing Suwen. The Jin Dynasty practitioner and advocate of acupuncture and moxibustion, Huangfu Mi (215–282), also quotes the Yellow Emperor in his Jiayi jing, c. 265. During the Tang Dynasty, the Suwen was expanded and revised and is now the best extant representation of the foundational roots of traditional Chinese medicine. Traditional Chinese Medicine that is based on the use of herbal medicine, acupuncture, massage and other forms of therapy has been practiced in China for thousands of years.

In the 18th century, during the Qing dynasty, there was a proliferation of popular books as well as more advanced encyclopedias on traditional medicine. Jesuit missionaries introduced Western science and medicine to the royal court, although the Chinese physicians ignored them. [34]

Finally in the 19th century, Western medicine was introduced at the local level by Christian medical missionaries from the London Missionary Society (Britain), the Methodist Church (Britain) and the Presbyterian Church (US). Benjamin Hobson (1816–1873) in 1839, set up a highly successful Wai Ai Clinic in Guangzhou, China. [35] The Hong Kong College of Medicine for Chinese was founded in 1887 by the London Missionary Society, with its first graduate (in 1892) being Sun Yat-sen, who later led the Chinese Revolution (1911). The Hong Kong College of Medicine for Chinese was the forerunner of the School of Medicine of the University of Hong Kong, which started in 1911.

Because of the social custom that men and women should not be near to one another, the women of China were reluctant to be treated by male doctors. The missionaries sent women doctors such as Dr. Mary Hannah Fulton (1854–1927). Supported by the Foreign Missions Board of the Presbyterian Church (US) she in 1902 founded the first medical college for women in China, the Hackett Medical College for Women, in Guangzhou. [36]

Historiography of Chinese Medicine Edit

When reading the Chinese classics, it is important for scholars to examine these works from the Chinese perspective. Historians have noted two key aspects of Chinese medical history: understanding conceptual differences when translating the term "身, and observing the history from the perspective of cosmology rather than biology. [37]

In Chinese classical texts, the term 身 is the closest historical translation to the English word "body" because it sometimes refers to the physical human body in terms of being weighed or measured, but the term is to be understood as an “ensemble of functions” encompassing both the human psyche and emotions. [38] This concept of the human body is opposed to the European duality of a separate mind and body. [39] It is critical for scholars to understand the fundamental differences in concepts of the body in order to connect the medical theory of the classics to the “human organism” it is explaining. [40]

Chinese scholars established a correlation between the cosmos and the “human organism.” The basic components of cosmology, qi, yin yang and the Five Phase theory, were used to explain health and disease in texts such as Huangdi neijing. [41] Yin and yang are the changing factors in cosmology, with qi as the vital force or energy of life. The Five phase theory Wu Xing of the Han dynasty contains the elements wood, fire, earth, metal, and water. By understanding medicine from a cosmology perspective, historians better understand Chinese medical and social classifications such as gender, which was defined by a domination or remission of yang in terms of yin.

These two distinctions are imperative when analyzing the history of traditional Chinese medical science.

A majority of Chinese medical history written after the classical canons comes in the form of primary source case studies where academic physicians record the illness of a particular person and the healing techniques used, as well as their effectiveness. [42] Historians have noted that Chinese scholars wrote these studies instead of “books of prescriptions or advice manuals” in their historical and environmental understanding, no two illnesses were alike so the healing strategies of the practitioner was unique every time to the specific diagnosis of the patient. [43] Medical case studies existed throughout Chinese history, but “individually authored and published case history” was a prominent creation of the Ming Dynasty. [44] An example such case studies would be the literati physician, Cheng Congzhou, collection of 93 cases published in 1644. [45]

Around 800 BCE Homer in The Iliad gives descriptions of wound treatment by the two sons of Asklepios, the admirable physicians Podaleirius and Machaon and one acting doctor, Patroclus. Because Machaon is wounded and Podaleirius is in combat Eurypylus asks Patroclus to cut out this arrow from my thigh, wash off the blood with warm water and spread soothing ointment on the wound. [46] Asklepios like Imhotep becomes god of healing over time.

Temples dedicated to the healer-god Asclepius, known as Asclepieia (Ancient Greek: Ἀσκληπιεῖα , sing. Ἀσκληπιεῖον , Asclepieion), functioned as centers of medical advice, prognosis, and healing. [47] At these shrines, patients would enter a dream-like state of induced sleep known as enkoimesis ( ἐγκοίμησις ) not unlike anesthesia, in which they either received guidance from the deity in a dream or were cured by surgery. [48] Asclepeia provided carefully controlled spaces conducive to healing and fulfilled several of the requirements of institutions created for healing. [47] In the Asclepeion of Epidaurus, three large marble boards dated to 350 BCE preserve the names, case histories, complaints, and cures of about 70 patients who came to the temple with a problem and shed it there. Some of the surgical cures listed, such as the opening of an abdominal abscess or the removal of traumatic foreign material, are realistic enough to have taken place, but with the patient in a state of enkoimesis induced with the help of soporific substances such as opium. [48] Alcmaeon of Croton wrote on medicine between 500 and 450 BCE. He argued that channels linked the sensory organs to the brain, and it is possible that he discovered one type of channel, the optic nerves, by dissection. [49]

Hippocrates Edit

A towering figure in the history of medicine was the physician Hippocrates of Kos (c. 460 – c. 370 BCE), considered the "father of modern medicine." [50] [51] The Hippocratic Corpus is a collection of around seventy early medical works from ancient Greece strongly associated with Hippocrates and his students. Most famously, the Hippocratics invented the Hippocratic Oath for physicians. Contemporary physicians swear an oath of office which includes aspects found in early editions of the Hippocratic Oath.

Hippocrates and his followers were first to describe many diseases and medical conditions. Though humorism (humoralism) as a medical system predates 5th-century Greek medicine, Hippocrates and his students systematized the thinking that illness can be explained by an imbalance of blood, phlegm, black bile, and yellow bile. [52] Hippocrates is given credit for the first description of clubbing of the fingers, an important diagnostic sign in chronic suppurative lung disease, lung cancer and cyanotic heart disease. For this reason, clubbed fingers are sometimes referred to as "Hippocratic fingers". [53] Hippocrates was also the first physician to describe the Hippocratic face in Prognosis. Shakespeare famously alludes to this description when writing of Falstaff's death in Act II, Scene iii. of Henry V. [54]

Hippocrates began to categorize illnesses as acute, chronic, endemic and epidemic, and use terms such as, "exacerbation, relapse, resolution, crisis, paroxysm, peak, and convalescence." [55] [56] [57]

Another of Hippocrates's major contributions may be found in his descriptions of the symptomatology, physical findings, surgical treatment and prognosis of thoracic empyema, i.e. suppuration of the lining of the chest cavity. His teachings remain relevant to present-day students of pulmonary medicine and surgery. Hippocrates was the first documented person to practise cardiothoracic surgery, and his findings are still valid.

Some of the techniques and theories developed by Hippocrates are now put into practice by the fields of Environmental and Integrative Medicine. These include recognizing the importance of taking a complete history which includes environmental exposures as well as foods eaten by the patient which might play a role in his or her illness.

Herophilus and Erasistratus Edit

Two great Alexandrians laid the foundations for the scientific study of anatomy and physiology, Herophilus of Chalcedon and Erasistratus of Ceos. [59] Other Alexandrian surgeons gave us ligature (hemostasis), lithotomy, hernia operations, ophthalmic surgery, plastic surgery, methods of reduction of dislocations and fractures, tracheotomy, and mandrake as an anaesthetic. Some of what we know of them comes from Celsus and Galen of Pergamum. [60]

Herophilus of Chalcedon, the renowned Alexandrian physician, was one of the pioneers of human anatomy. Though his knowledge of the anatomical structure of the human body was vast, he specialized in the aspects of neural anatomy. [61] Thus, his experimentation was centered around the anatomical composition of the blood-vascular system and the pulsations that can be analyzed from the system. [61] Furthermore, the surgical experimentation he administered caused him to become very prominent throughout the field of medicine, as he was one of the first physicians to initiate the exploration and dissection of the human body. [62]

The banned practice of human dissection was lifted during his time within the scholastic community. This brief moment in the history of Greek medicine allowed him to further study the brain, which he believed was the core of the nervous system. [62] He also distinguished between veins and arteries, noting that the latter pulse and the former do not. Thus, while working at the medical school of Alexandria, Herophilus placed intelligence in the brain based on his surgical exploration of the body, and he connected the nervous system to motion and sensation. In addition, he and his contemporary, Erasistratus of Chios, continued to research the role of veins and nerves. After conducting extensive research, the two Alexandrians mapped out the course of the veins and nerves across the human body. Erasistratus connected the increased complexity of the surface of the human brain compared to other animals to its superior intelligence. He sometimes employed experiments to further his research, at one time repeatedly weighing a caged bird, and noting its weight loss between feeding times. [63] In Erasistratus' physiology, air enters the body, is then drawn by the lungs into the heart, where it is transformed into vital spirit, and is then pumped by the arteries throughout the body. Some of this vital spirit reaches the brain, where it is transformed into animal spirit, which is then distributed by the nerves. [63]

Galen Edit

The Greek Galen (c. 129–216 AD) was one of the greatest physicians of the ancient world, as his theories dominated all medical studies for nearly 1500 years. [64] His theories and experimentation laid the foundation for modern medicine surrounding the heart and blood. Galen's influence and innovations in medicine can be contributed to the experiments he conducted, which were unlike any other medical experiments of his time. Galen strongly believed that medical dissection was one of the essential procedures in truly understanding medicine. He began to dissect different animals that were anatomically similar to humans, which allowed him to learn more about the internal organs and extrapolate the surgical studies to the human body. [64] In addition, he performed many audacious operations—including brain and eye surgeries—that were not tried again for almost two millennia. Through the dissections and surgical procedures, Galen concluded that blood is able to circulate throughout the human body, and the heart is most similar to the human soul. [64] [65] In Ars medica ("Arts of Medicine"), he further explains the mental properties in terms of specific mixtures of the bodily organs. [66] [67] While much of his work surrounded the physical anatomy, he also worked heavily in humoural physiology.

Galen's medical work was regarded as authoritative until well into the Middle Ages. He left a physiological model of the human body that became the mainstay of the medieval physician's university anatomy curriculum. Although he attempted to extrapolate the animal dissections towards the model of the human body, some of Galen's theories were incorrect. This caused his model to suffer greatly from stasis and intellectual stagnation. [68] Greek and Roman taboos caused dissection of the human body to usually be banned in ancient times, but in the Middle Ages it changed. [69] [70]

In 1523 Galen's On the Natural Faculties was published in London. In the 1530s Belgian anatomist and physician Andreas Vesalius launched a project to translate many of Galen's Greek texts into Latin. Vesalius's most famous work, De humani corporis fabrica was greatly influenced by Galenic writing and form. [71]

Roman contributions Edit

The Romans invented numerous surgical instruments, including the first instruments unique to women, [72] as well as the surgical uses of forceps, scalpels, cautery, cross-bladed scissors, the surgical needle, the sound, and speculas. [73] [74] Romans also performed cataract surgery. [75]

The Roman army physician Dioscorides (c. 40–90 CE), was a Greek botanist and pharmacologist. He wrote the encyclopedia De Materia Medica describing over 600 herbal cures, forming an influential pharmacopoeia which was used extensively for the following 1,500 years. [76]

Early Christians in the Roman Empire incorporated medicine into their theology, ritual practices, and metaphors. [77]

Byzantine Empire and Sassanid Empire Edit

Byzantine medicine encompasses the common medical practices of the Byzantine Empire from about 400 AD to 1453 AD. Byzantine medicine was notable for building upon the knowledge base developed by its Greco-Roman predecessors. In preserving medical practices from antiquity, Byzantine medicine influenced Islamic medicine as well as fostering the Western rebirth of medicine during the Renaissance.

Byzantine physicians often compiled and standardized medical knowledge into textbooks. Their records tended to include both diagnostic explanations and technical drawings. The Medical Compendium in Seven Books, written by the leading physician Paul of Aegina, survived as a particularly thorough source of medical knowledge. This compendium, written in the late seventh century, remained in use as a standard textbook for the following 800 years.

Late antiquity ushered in a revolution in medical science, and historical records often mention civilian hospitals (although battlefield medicine and wartime triage were recorded well before Imperial Rome). Constantinople stood out as a center of medicine during the Middle Ages, which was aided by its crossroads location, wealth, and accumulated knowledge.

The first ever known example of separating conjoined twins occurred in the Byzantine Empire in the 10th century. The next example of separating conjoined twins will be first recorded many centuries later in Germany in 1689. [78] [79]

The Byzantine Empire's neighbors, the Persian Sassanid Empire, also made their noteworthy contributions mainly with the establishment of the Academy of Gondeshapur, which was "the most important medical center of the ancient world during the 6th and 7th centuries." [80] In addition, Cyril Elgood, British physician and a historian of medicine in Persia, commented that thanks to medical centers like the Academy of Gondeshapur, "to a very large extent, the credit for the whole hospital system must be given to Persia." [81]

Islamic world Edit

The Islamic civilization rose to primacy in medical science as its physicians contributed significantly to the field of medicine, including anatomy, ophthalmology, pharmacology, pharmacy, physiology, and surgery. The Arabs were influenced by ancient Indian, Persian, Greek, Roman and Byzantine medical practices, and helped them develop further. [82] Galen & Hippocrates were pre-eminent authorities. The translation of 129 of Galen's works into Arabic by the Nestorian Christian Hunayn ibn Ishaq and his assistants, and in particular Galen's insistence on a rational systematic approach to medicine, set the template for Islamic medicine, which rapidly spread throughout the Arab Empire. [83] Its most famous physicians included the Persian polymaths Muhammad ibn Zakarīya al-Rāzi and Avicenna, who wrote more than 40 works on health, medicine, and well-being. Taking leads from Greece and Rome, Islamic scholars kept both the art and science of medicine alive and moving forward. [84] Persian polymath Avicenna has also been called the "father of medicine". [85] He wrote The Canon of Medicine which became a standard medical text at many medieval European universities, [86] considered one of the most famous books in the history of medicine. [87] The Canon of Medicine presents an overview of the contemporary medical knowledge of the medieval Islamic world, which had been influenced by earlier traditions including Greco-Roman medicine (particularly Galen), [88] Persian medicine, Chinese medicine and Indian medicine. Persian physician al-Rāzi [89] was one of the first to question the Greek theory of humorism, which nevertheless remained influential in both medieval Western and medieval Islamic medicine. [90] Some volumes of al-Rāzi's work Al-Mansuri, namely "On Surgery" and "A General Book on Therapy", became part of the medical curriculum in European universities. [91] Additionally, he has been described as a doctor's doctor, [92] the father of pediatrics, [93] [94] and a pioneer of ophthalmology. For example, he was the first to recognize the reaction of the eye's pupil to light. [94]

In addition to contributions to mankind’s understanding of human anatomy, Islamicate scientists and scholars, physicians specifically, played an invaluable role in the development of the modern hospital system, creating the foundations on which more contemporary medical professionals would build models of public health systems in Europe and elsewhere. [95] During the time of the Safavid empire (16th-18th centuries) in Iran and the Mughal empire (16th-19th centuries) in India, Muslim scholars radically transformed the institution of the hospital, creating an environment in which rapidly developing medical knowledge of the time could be passed among students and teachers from a wide range of cultures. [96] There were two main schools of thought with patient care at the time. These included humoural physiology from the Persians and Ayurvedic practice. After these theories were translated from Sanskrit to Persian and vice-versa, hospitals could have a mix of culture and techniques. This allowed for a sense of collaborative medicine. Hospitals became increasingly common during this period as wealthy patrons commonly founded them. Many features that are still in use today, such as an emphasis on hygiene, a staff fully dedicated to the care of patients, and separation of individual patients from each other were developed in Islamicate hospitals long before they came into practice in Europe. [97] At the time, the patient care aspects of hospitals in Europe had not taken effect. European hospitals were places of religion rather than institutions of science. As was the case with much of the scientific work done by Islamicate scholars, many of these novel developments in medical practice were transmitted to European cultures hundreds of years after they had long been utilized throughout the Islamicate world. Although Islamicate scientists were responsible for discovering much of the knowledge that allows the hospital system to function safely today, European scholars who built on this work still receive the majority of the credit historically [98]

Before the development of scientific medical practices in the Islamicate empires, medical care was mainly performed by religious figures such as priests. [95] Without a profound understanding of how infectious diseases worked and why sickness spread from person to person, these early attempts at caring for the ill and injured often did more harm than good. Contrarily, with the development of new and safer practices by Islamicate scholars and physicians in Arabian hospitals, ideas vital for the effective care of patients were developed, learned, and transmitted widely. Hospitals served as a way to spread these novel and necessary practices, some of which included separation of men and women patients, use of pharmacies for storing and keeping track of medications, keeping of patient records, and personal and institutional sanitation and hygiene. [95] Much of this knowledge was recorded and passed on through Islamicate medical texts, many of which were carried to Europe and translated for the use of European medical workers. The Tasrif, written by surgeon Abu Al-Qasim Al-Zahrawi, was translated into Latin it became one of the most important medical texts in European universities during the Middle Ages and contained useful information on surgical techniques and spread of bacterial infection. [95]

The hospital was a typical institution included in the majority of Muslim cities, and although they were often physically attached to religious institutions, they were not themselves places of religious practice. [96] Rather, they served as facilities in which education and scientific innovation could flourish. If they had places of worship, they were secondary to the medical side of the hospital. Islamicate hospitals, along with observatories used for astronomical science, were some of the most important points of exchange for the spread of scientific knowledge. Undoubtedly, the hospital system developed in the Islamicate world played an invaluable role in the creation and evolution of the hospitals we as a society know and depend on today.

Europe Edit

After AD 400, the study and practice of medicine in the Western Roman Empire went into deep decline. Medical services were provided, especially for the poor, in the thousands of monastic hospitals that sprang up across Europe, but the care was rudimentary and mainly palliative. [99] Most of the writings of Galen and Hippocrates were lost to the West, with the summaries and compendia of St. Isidore of Seville being the primary channel for transmitting Greek medical ideas. [100] The Carolingian renaissance brought increased contact with Byzantium and a greater awareness of ancient medicine, [101] but only with the twelfth-century renaissance and the new translations coming from Muslim and Jewish sources in Spain, and the fifteenth-century flood of resources after the fall of Constantinople did the West fully recover its acquaintance with classical antiquity.

Greek and Roman taboos had meant that dissection was usually banned in ancient times, but in the Middle Ages it changed: medical teachers and students at Bologna began to open human bodies, and Mondino de Luzzi (c. 1275–1326) produced the first known anatomy textbook based on human dissection. [69] [70]

Wallis identifies a prestige hierarchy with university educated physicians on top, followed by learned surgeons craft-trained surgeons barber surgeons itinerant specialists such as dentist and oculists empirics and midwives. [102]

Schools Edit

The first medical schools were opened in the 9th century, most notably the Schola Medica Salernitana at Salerno in southern Italy. The cosmopolitan influences from Greek, Latin, Arabic, and Hebrew sources gave it an international reputation as the Hippocratic City. Students from wealthy families came for three years of preliminary studies and five of medical studies. The medicine, following the laws of Federico II, that he founded in 1224 the University ad improved the Schola Salernitana, in the period between 1200 and 1400, it had in Sicily (so-called Sicilian Middle Ages) a particular development so much to create a true school of Jewish medicine. [103]

As a result of which, after a legal examination, was conferred to a Jewish Sicilian woman, Virdimura, wife of another physician Pasquale of Catania, the historical record of before woman officially trained to exercise of the medical profession. [104]

By the thirteenth century, the medical school at Montpellier began to eclipse the Salernitan school. In the 12th century, universities were founded in Italy, France, and England, which soon developed schools of medicine. The University of Montpellier in France and Italy's University of Padua and University of Bologna were leading schools. Nearly all the learning was from lectures and readings in Hippocrates, Galen, Avicenna, and Aristotle. In later centuries, the importance of universities founded in the late Middle Ages gradually increased, e.g. Charles University in Prague (established in 1348), Jagiellonian University in Cracow (1364), University of Vienna (1365), Heidelberg University (1386) and University of Greifswald (1456).

Humors Edit

The theory of humors was derived from ancient medical works, dominated western medicine until the 19th century, and is credited to Greek philosopher and surgeon Galen of Pergamon (129-ca. 216 A.D.). [105] In Greek medicine, there are thought to be four humors, or bodily fluids that are linked to illness: blood, phlegm, yellow bile, and black bile. [106] Early scientists believed that food is digested into blood, muscle, and bones, while the humors that weren't blood were then formed by indigestible materials that are left over. An excess or shortage of any one of the four humors is theorized to cause an imbalance that results in sickness the aforementioned statement was hypothesized by sources before Hippocrates. [106] Hippocrates (ca. 400 B.C.) deduced that the four seasons of the year and four ages of man that affect the body in relation to the humors. [105] The four ages of man are childhood, youth, prime age, and old age. [106] The four humors as associated with the four seasons are black bile-autumn, yellow bile-summer, phlegm-winter and blood-spring. [107] In De temperamentis, Galen linked what he called temperaments, or personality characteristics, to a person's natural mixture of humors. He also said that the best place to check the balance of temperaments was in the palm of the hand. A person that is considered to be phlegmatic is said to be an introvert, even-tempered, calm, and peaceful. [106] This person would have an excess of phlegm, which is described as a viscous substance or mucous. [108] Similarly, a melancholic temperament related to being moody, anxious, depressed, introverted, and pessimistic. [106] A melancholic temperament is caused by an excess of black bile, which is sedimentary and dark in color. [108] Being extroverted, talkative, easygoing, carefree, and sociable coincides with a sanguine temperament, which is linked to too much blood. [106] Finally, a choleric temperament is related to too much yellow bile, which is actually red in color and has the texture of foam it is associated with being aggressive, excitable, impulsive, and also extroverted. There are numerous ways to treat a disproportion of the humors. For example, if someone was suspected to have too much blood, then the physician would perform bloodletting as a treatment. Likewise, if a person that had too much phlegm would feel better after expectorating, and someone with too much yellow bile would purge. [108] Another factor to be considered in the balance of humors is the quality of air in which one resides, such as the climate and elevation. Also, the standard of food and drink, balance of sleeping and waking, exercise and rest, retention and evacuation are important. Moods such as anger, sadness, joy, and love can affect the balance. During that time, the importance of balance was demonstrated by the fact that women lose blood monthly during menstruation, and have a lesser occurrence of gout, arthritis, and epilepsy then men do. [108] Galen also hypothesized that there are three faculties. The natural faculty affects growth and reproduction and is produced in the liver. Animal or vital faculty controls respiration and emotion, coming from the heart. In the brain, the psychic faculty commands the senses and thought. [108] The structure of bodily functions is related to the humors as well. Greek physicians understood that food was cooked in the stomach this is where the nutrients are extracted. The best, most potent and pure nutrients from food are reserved for blood, which is produced in the liver and carried through veins to organs. Blood enhanced with pneuma, which means wind or breath, is carried by the arteries. [106] The path that blood take is as follows: venous blood passes through the vena cava and is moved into the right ventricle of the heart then, the pulmonary artery takes it to the lungs. [108] Later, the pulmonary vein then mixes air from the lungs with blood to form arterial blood, which has different observable characteristics. [106] After leaving the liver, half of the yellow bile that is produced travels to the blood, while the other half travels to the gallbladder. Similarly, half of the black bile produced gets mixed in with blood, and the other half is used by the spleen. [108]

Women Edit

In 1376, in Sicily, it was historically given, in relationship to the laws of Federico II that they foresaw an examination with a regal errand of physicists, the first qualification to the exercise of the medicine to a woman, Virdimura a Jewish woman of Catania, whose document is preserved in Palermo to the Italian national archives. [109]

The Renaissance brought an intense focus on scholarship to Christian Europe. A major effort to translate the Arabic and Greek scientific works into Latin emerged. Europeans gradually became experts not only in the ancient writings of the Romans and Greeks, but in the contemporary writings of Islamic scientists. During the later centuries of the Renaissance came an increase in experimental investigation, particularly in the field of dissection and body examination, thus advancing our knowledge of human anatomy. [110]

The development of modern neurology began in the 16th century in Italy and France with Niccolò Massa, Jean Fernel, Jacques Dubois and Andreas Vesalius. Vesalius described in detail the anatomy of the brain and other organs he had little knowledge of the brain's function, thinking that it resided mainly in the ventricles. Over his lifetime he corrected over 200 of Galen's mistakes. Understanding of medical sciences and diagnosis improved, but with little direct benefit to health care. Few effective drugs existed, beyond opium and quinine. Folklore cures and potentially poisonous metal-based compounds were popular treatments. Independently from Ibn al-Nafis, Michael Servetus rediscovered the pulmonary circulation, but this discovery did not reach the public because it was written down for the first time in the "Manuscript of Paris" [111] in 1546, and later published in the theological work which he paid with his life in 1553. Later this was perfected by Renaldus Columbus and Andrea Cesalpino.

In 1628 the English physician William Harvey made a ground-breaking discovery when he correctly described the circulation of the blood in his Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus. Before this time the most useful manual in medicine used both by students and expert physicians was Dioscorides' De Materia Medica, a pharmacopoeia.

Bacteria and protists were first observed with a microscope by Antonie van Leeuwenhoek in 1676, initiating the scientific field of microbiology. [112]

Paracelsus Edit

Paracelsus (1493–1541), was an erratic and abusive innovator who rejected Galen and bookish knowledge, calling for experimental research, with heavy doses of mysticism, alchemy and magic mixed in. He rejected sacred magic (miracles) under Church auspices and looked for cures in nature. [113] He preached but he also pioneered the use of chemicals and minerals in medicine. His hermetical views were that sickness and health in the body relied on the harmony of man (microcosm) and Nature (macrocosm). He took an approach different from those before him, using this analogy not in the manner of soul-purification but in the manner that humans must have certain balances of minerals in their bodies, and that certain illnesses of the body had chemical remedies that could cure them. [114] Most of his influence came after his death. Paracelsus is a highly controversial figure in the history of medicine, with most experts hailing him as a Father of Modern Medicine for shaking off religious orthodoxy and inspiring many researchers others say he was a mystic more than a scientist and downplay his importance. [115] [116]

Padua and Bologna Edit

University training of physicians began in the 13th century.

The University of Padua was founded about 1220 by walkouts from the University of Bologna, and began teaching medicine in 1222. It played a leading role in the identification and treatment of diseases and ailments, specializing in autopsies and the inner workings of the body. [117] Starting in 1595, Padua's famous anatomical theatre drew artists and scientists studying the human body during public dissections. The intensive study of Galen led to critiques of Galen modeled on his own writing, as in the first book of Vesalius's De humani corporis fabrica. Andreas Vesalius held the chair of Surgery and Anatomy (explicator chirurgiae) and in 1543 published his anatomical discoveries in De Humani Corporis Fabrica. He portrayed the human body as an interdependent system of organ groupings. The book triggered great public interest in dissections and caused many other European cities to establish anatomical theatres. [118]

At the University of Bologna the training of physicians began in 1219. The Italian city attracted students from across Europe. Taddeo Alderotti built a tradition of medical education that established the characteristic features of Italian learned medicine and was copied by medical schools elsewhere. Turisanus (d. 1320) was his student. [119] The curriculum was revised and strengthened in 1560–1590. [120] A representative professor was Julius Caesar Aranzi (Arantius) (1530–89). He became Professor of Anatomy and Surgery at the University of Bologna in 1556, where he established anatomy as a major branch of medicine for the first time. Aranzi combined anatomy with a description of pathological processes, based largely on his own research, Galen, and the work of his contemporary Italians. Aranzi discovered the 'Nodules of Aranzio' in the semilunar valves of the heart and wrote the first description of the superior levator palpebral and the coracobrachialis muscles. His books (in Latin) covered surgical techniques for many conditions, including hydrocephalus, nasal polyp, goitre and tumours to phimosis, ascites, haemorrhoids, anal abscess and fistulae. [121]

Women Edit

Catholic women played large roles in health and healing in medieval and early modern Europe. [122] A life as a nun was a prestigious role wealthy families provided dowries for their daughters, and these funded the convents, while the nuns provided free nursing care for the poor. [123]

The Catholic elites provided hospital services because of their theology of salvation that good works were the route to heaven. The Protestant reformers rejected the notion that rich men could gain God's grace through good works—and thereby escape purgatory—by providing cash endowments to charitable institutions. They also rejected the Catholic idea that the poor patients earned grace and salvation through their suffering. [124] Protestants generally closed all the convents [125] and most of the hospitals, sending women home to become housewives, often against their will. [126] On the other hand, local officials recognized the public value of hospitals, and some were continued in Protestant lands, but without monks or nuns and in the control of local governments. [127]

In London, the crown allowed two hospitals to continue their charitable work, under nonreligious control of city officials. [128] The convents were all shut down but Harkness finds that women—some of them former nuns—were part of a new system that delivered essential medical services to people outside their family. They were employed by parishes and hospitals, as well as by private families, and provided nursing care as well as some medical, pharmaceutical, and surgical services. [129]

Meanwhile, in Catholic lands such as France, rich families continued to fund convents and monasteries, and enrolled their daughters as nuns who provided free health services to the poor. Nursing was a religious role for the nurse, and there was little call for science. [130]

Age of Enlightenment Edit

During the Age of Enlightenment, the 18th century, science was held in high esteem and physicians upgraded their social status by becoming more scientific. The health field was crowded with self-trained barber-surgeons, apothecaries, midwives, drug peddlers, and charlatans.

Across Europe medical schools relied primarily on lectures and readings. The final year student would have limited clinical experience by trailing the professor through the wards. Laboratory work was uncommon, and dissections were rarely done because of legal restrictions on cadavers. Most schools were small, and only Edinburgh, Scotland, with 11,000 alumni, produced large numbers of graduates. [131] [132]

Britain Edit

In Britain, there were but three small hospitals after 1550. Pelling and Webster estimate that in London in the 1580 to 1600 period, out of a population of nearly 200,000 people, there were about 500 medical practitioners. Nurses and midwives are not included. There were about 50 physicians, 100 licensed surgeons, 100 apothecaries, and 250 additional unlicensed practitioners. In the last category about 25% were women. [133] All across Britain—and indeed all of the world—the vast majority of the people in city, town or countryside depended for medical care on local amateurs with no professional training but with a reputation as wise healers who could diagnose problems and advise sick people what to do—and perhaps set broken bones, pull a tooth, give some traditional herbs or brews or perform a little magic to cure what ailed them.

The London Dispensary opened in 1696, the first clinic in the British Empire to dispense medicines to poor sick people. The innovation was slow to catch on, but new dispensaries were open in the 1770s. In the colonies, small hospitals opened in Philadelphia in 1752, New York in 1771, and Boston (Massachusetts General Hospital) in 1811. [134]

Guy's Hospital, the first great British hospital with a modern foundation opened in 1721 in London, with funding from businessman Thomas Guy. It had been preceded by St Bartholomew's Hospital and St Thomas's Hospital, both medieval foundations. In 1821 a bequest of £200,000 by William Hunt in 1829 funded expansion for an additional hundred beds at Guy's. Samuel Sharp (1709–78), a surgeon at Guy's Hospital from 1733 to 1757, was internationally famous his A Treatise on the Operations of Surgery (1st ed., 1739), was the first British study focused exclusively on operative technique. [135]

English physician Thomas Percival (1740–1804) wrote a comprehensive system of medical conduct, Medical Ethics or, a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons (1803) that set the standard for many textbooks. [136]

Spain and Spanish Empire Edit

In the Spanish Empire, the viceregal capital of Mexico City was a site of medical training for physicians and the creation of hospitals. Epidemic disease had decimated indigenous populations starting with the early sixteenth-century Spanish conquest of the Aztec empire, when a black auxiliary in the armed forces of conqueror Hernán Cortés, with an active case of smallpox, set off a virgin land epidemic among indigenous peoples, Spanish allies and enemies alike. Aztec emperor Cuitlahuac died of smallpox. [137] [138] Disease was a significant factor in the Spanish conquest elsewhere as well. [139]

Medical education instituted at the Royal and Pontifical University of Mexico chiefly served the needs of urban elites. Male and female curanderos or lay practitioners, attended to the ills of the popular classes. The Spanish crown began regulating the medical profession just a few years after the conquest, setting up the Royal Tribunal of the Protomedicato, a board for licensing medical personnel in 1527. Licensing became more systematic after 1646 with physicians, druggists, surgeons, and bleeders requiring a license before they could publicly practice. [140] Crown regulation of medical practice became more general in the Spanish empire. [141]

Elites and the popular classes alike called on divine intervention in personal and society-wide health crises, such as the epidemic of 1737. The intervention of the Virgin of Guadalupe was depicted in a scene of dead and dying Indians, with elites on their knees praying for her aid. In the late eighteenth century, the crown began implementing secularizing policies on the Iberian peninsula and its overseas empire to control disease more systematically and scientifically. [142] [143] [144]

Spanish Quest for Medicinal Spices Edit

Botanical medicines also became popular during the 16th, 17th, and 18th Centuries. Spanish pharmaceutical books during this time contain medicinal recipes consisting of spices, herbs, and other botanical products. For example, nutmeg oil was documented for curing stomach ailments and cardamom oil was believed to relieve intestinal ailments. [145] During the rise of the global trade market, spices and herbs, along with many other goods, that were indigenous to different territories began to appear in different locations across the globe. Herbs and spices were especially popular for their utility in cooking and medicines. As a result of this popularity and increased demand for spices, some areas in Asia, like China and Indonesia, became hubs for spice cultivation and trade. [146] The Spanish Empire also wanted to benefit from the international spice trade, so they looked towards their American colonies.

The Spanish American colonies became an area where the Spanish searched to discover new spices and indigenous American medicinal recipes. The Florentine Codex, a 16th-century ethnographic research study in Mesoamerica by the Spanish Franciscan friar Bernardino de Sahagún, is a major contribution to the history of Nahua medicine. [147] The Spanish did discover many spices and herbs new to them, some of which were reportedly similar to Asian spices. A Spanish physician by the name of Nicolás Monardes studied many of the American spices coming into Spain. He documented many of the new American spices and their medicinal properties in his survey Historia medicinal de las cosas que se traen de nuestras Indias Occidentales. For example, Monardes describes the "Long Pepper" (Pimienta luenga), found along the coasts of the countries that are now known Panama and Colombia, as a pepper that was more flavorful, healthy, and spicy in comparison to the Eastern black pepper. [145] The Spanish interest in American spices can first be seen in the commissioning of the Libellus de Medicinalibus Indorum Herbis, which was a Spanish-American codex describing indigenous American spices and herbs and describing the ways that these were used in natural Aztec medicines. The codex was commissioned in the year 1552 by Francisco de Mendoza, the son of Antonio de Mendoza, who was the first Viceroy of New Spain. [145] Francisco de Mendoza was interested in studying the properties of these herbs and spices, so that he would be able to profit from the trade of these herbs and the medicines that could be produced by them.

Francisco de Mendoza recruited the help of Monardez in studying the traditional medicines of the indigenous people living in what was then the Spanish colonies. Monardez researched these medicines and performed experiments to discover the possibilities of spice cultivation and medicine creation in the Spanish colonies. The Spanish transplanted some herbs from Asia, but only a few foreign crops were successfully grown in the Spanish Colonies. One notable crop brought from Asia and successfully grown in the Spanish colonies was ginger, as it was considered Hispaniola's number 1 crop at the end of the 16th Century. [145] The Spanish Empire did profit from cultivating herbs and spices, but they also introduced pre-Columbian American medicinal knowledge to Europe. Other Europeans were inspired by the actions of Spain and decided to try to establish a botanical transplant system in colonies that they controlled, however, these subsequent attempts were not successful. [146]

The practice of medicine changed in the face of rapid advances in science, as well as new approaches by physicians. Hospital doctors began much more systematic analysis of patients' symptoms in diagnosis. [148] Among the more powerful new techniques were anaesthesia, and the development of both antiseptic and aseptic operating theatres. [149] Effective cures were developed for certain endemic infectious diseases. However, the decline in many of the most lethal diseases was due more to improvements in public health and nutrition than to advances in medicine. [ citation needed ] [150]

Medicine was revolutionized in the 19th century and beyond by advances in chemistry, laboratory techniques, and equipment. Old ideas of infectious disease epidemiology were gradually replaced by advances in bacteriology and virology. [112]

Germ theory and bacteriology Edit

In the 1830s in Italy, Agostino Bassi traced the silkworm disease muscardine to microorganisms. Meanwhile, in Germany, Theodor Schwann led research on alcoholic fermentation by yeast, proposing that living microorganisms were responsible. Leading chemists, such as Justus von Liebig, seeking solely physicochemical explanations, derided this claim and alleged that Schwann was regressing to vitalism.

In 1847 in Vienna, Ignaz Semmelweis (1818–1865), dramatically reduced the death rate of new mothers (due to childbed fever) by requiring physicians to clean their hands before attending childbirth, yet his principles were marginalized and attacked by professional peers. [151] At that time most people still believed that infections were caused by foul odors called miasmas.

French scientist Louis Pasteur confirmed Schwann's fermentation experiments in 1857 and afterwards supported the hypothesis that yeast were microorganisms. Moreover, he suggested that such a process might also explain contagious disease. In 1860, Pasteur's report on bacterial fermentation of butyric acid motivated fellow Frenchman Casimir Davaine to identify a similar species (which he called bacteridia) as the pathogen of the deadly disease anthrax. Others dismissed "bacteridia" as a mere byproduct of the disease. British surgeon Joseph Lister, however, took these findings seriously and subsequently introduced antisepsis to wound treatment in 1865.

German physician Robert Koch, noting fellow German Ferdinand Cohn's report of a spore stage of a certain bacterial species, traced the life cycle of Davaine's bacteridia, identified spores, inoculated laboratory animals with them, and reproduced anthrax—a breakthrough for experimental pathology and germ theory of disease. Pasteur's group added ecological investigations confirming spores' role in the natural setting, while Koch published a landmark treatise in 1878 on the bacterial pathology of wounds. In 1881, Koch reported discovery of the "tubercle bacillus", cementing germ theory and Koch's acclaim.

Upon the outbreak of a cholera epidemic in Alexandria, Egypt, two medical missions went to investigate and attend the sick, one was sent out by Pasteur and the other led by Koch. [152] Koch's group returned in 1883, having successfully discovered the cholera pathogen. [152] In Germany, however, Koch's bacteriologists had to vie against Max von Pettenkofer, Germany's leading proponent of miasmatic theory. [153] Pettenkofer conceded bacteria's casual involvement, but maintained that other, environmental factors were required to turn it pathogenic, and opposed water treatment as a misdirected effort amid more important ways to improve public health. [153] The massive cholera epidemic in Hamburg in 1892 devastated Pettenkoffer's position, and yielded German public health to "Koch's bacteriology". [153]

On losing the 1883 rivalry in Alexandria, Pasteur switched research direction, and introduced his third vaccine—rabies vaccine—the first vaccine for humans since Jenner's for smallpox. [152] From across the globe, donations poured in, funding the founding of Pasteur Institute, the globe's first biomedical institute, which opened in 1888. [152] Along with Koch's bacteriologists, Pasteur's group—which preferred the term microbiology—led medicine into the new era of "scientific medicine" upon bacteriology and germ theory. [152] Accepted from Jakob Henle, Koch's steps to confirm a species' pathogenicity became famed as "Koch's postulates". Although his proposed tuberculosis treatment, tuberculin, seemingly failed, it soon was used to test for infection with the involved species. In 1905, Koch was awarded the Nobel Prize in Physiology or Medicine, and remains renowned as the founder of medical microbiology. [154]

Women Edit

Women as healers Edit

Women have always served as healers and midwives since ancient times. However, the professionalization of medicine forced them increasingly to the sidelines. As hospitals multiplied they relied in Europe on orders of Roman Catholic nun-nurses, and German Protestant and Anglican deaconesses in the early 19th century. They were trained in traditional methods of physical care that involved little knowledge of medicine. The breakthrough to professionalization based on knowledge of advanced medicine was led by Florence Nightingale in England. She resolved to provide more advanced training than she saw on the Continent. At Kaiserswerth, where the first German nursing schools were founded in 1836 by Theodor Fliedner, she said, "The nursing was nil and the hygiene horrible." [155] ) Britain's male doctors preferred the old system, but Nightingale won out and her Nightingale Training School opened in 1860 and became a model. The Nightingale solution depended on the patronage of upper-class women, and they proved eager to serve. Royalty became involved. In 1902 the wife of the British king took control of the nursing unit of the British army, became its president, and renamed it after herself as the Queen Alexandra's Royal Army Nursing Corps when she died the next queen became president. Today its Colonel In Chief is Sophie, Countess of Wessex, the daughter-in-law of Queen Elizabeth II. In the United States, upper-middle-class women who already supported hospitals promoted nursing. The new profession proved highly attractive to women of all backgrounds, and schools of nursing opened in the late 19th century. They soon a function of large hospitals [ clarification needed ] , where they provided a steady stream of low-paid idealistic workers. The International Red Cross began operations in numerous countries in the late 19th century, promoting nursing as an ideal profession for middle-class women. [156]

The Nightingale model was widely copied. Linda Richards (1841–1930) studied in London and became the first professionally trained American nurse. She established nursing training programs in the United States and Japan, and created the first system for keeping individual medical records for hospitalized patients. [157] The Russian Orthodox Church sponsored seven orders of nursing sisters in the late 19th century. They ran hospitals, clinics, almshouses, pharmacies, and shelters as well as training schools for nurses. In the Soviet era (1917–1991), with the aristocratic sponsors gone, nursing became a low-prestige occupation based in poorly maintained hospitals. [158]

Women as physicians Edit

It was very difficult for women to become doctors in any field before the 1970s. Elizabeth Blackwell (1821–1910) became the first woman to formally study and practice medicine in the United States. She was a leader in women's medical education. While Blackwell viewed medicine as a means for social and moral reform, her student Mary Putnam Jacobi (1842–1906) focused on curing disease. At a deeper level of disagreement, Blackwell felt that women would succeed in medicine because of their humane female values, but Jacobi believed that women should participate as the equals of men in all medical specialties using identical methods, values and insights. [159] In the Soviet Union although the majority of medical doctors were women, they were paid less than the mostly male factory workers. [160]

Paris Edit

Paris (France) and Vienna were the two leading medical centers on the Continent in the era 1750–1914.

In the 1770s–1850s Paris became a world center of medical research and teaching. The "Paris School" emphasized that teaching and research should be based in large hospitals and promoted the professionalization of the medical profession and the emphasis on sanitation and public health. A major reformer was Jean-Antoine Chaptal (1756–1832), a physician who was Minister of Internal Affairs. He created the Paris Hospital, health councils, and other bodies. [161]

Louis Pasteur (1822–1895) was one of the most important founders of medical microbiology. He is remembered for his remarkable breakthroughs in the causes and preventions of diseases. His discoveries reduced mortality from puerperal fever, and he created the first vaccines for rabies and anthrax. His experiments supported the germ theory of disease. He was best known to the general public for inventing a method to treat milk and wine in order to prevent it from causing sickness, a process that came to be called pasteurization. He is regarded as one of the three main founders of microbiology, together with Ferdinand Cohn and Robert Koch. He worked chiefly in Paris and in 1887 founded the Pasteur Institute there to perpetuate his commitment to basic research and its practical applications. As soon as his institute was created, Pasteur brought together scientists with various specialties. The first five departments were directed by Emile Duclaux (general microbiology research) and Charles Chamberland (microbe research applied to hygiene), as well as a biologist, Ilya Ilyich Mechnikov (morphological microbe research) and two physicians, Jacques-Joseph Grancher (rabies) and Emile Roux (technical microbe research). One year after the inauguration of the Institut Pasteur, Roux set up the first course of microbiology ever taught in the world, then entitled Cours de Microbie Technique (Course of microbe research techniques). It became the model for numerous research centers around the world named "Pasteur Institutes." [162] [163]

Vienna Edit

The First Viennese School of Medicine, 1750–1800, was led by the Dutchman Gerard van Swieten (1700–1772), who aimed to put medicine on new scientific foundations—promoting unprejudiced clinical observation, botanical and chemical research, and introducing simple but powerful remedies. When the Vienna General Hospital opened in 1784, it at once became the world's largest hospital and physicians acquired a facility that gradually developed into the most important research centre. [164] Progress ended with the Napoleonic wars and the government shutdown in 1819 of all liberal journals and schools this caused a general return to traditionalism and eclecticism in medicine. [165]

Vienna was the capital of a diverse empire and attracted not just Germans but Czechs, Hungarians, Jews, Poles and others to its world-class medical facilities. After 1820 the Second Viennese School of Medicine emerged with the contributions of physicians such as Carl Freiherr von Rokitansky, Josef Škoda, Ferdinand Ritter von Hebra, and Ignaz Philipp Semmelweis. Basic medical science expanded and specialization advanced. Furthermore, the first dermatology, eye, as well as ear, nose, and throat clinics in the world were founded in Vienna. The textbook of ophthalmologist Georg Joseph Beer (1763–1821) Lehre von den Augenkrankheiten combined practical research and philosophical speculations, and became the standard reference work for decades. [166]

Berlin Edit

After 1871 Berlin, the capital of the new German Empire, became a leading center for medical research. Robert Koch (1843–1910) was a representative leader. He became famous for isolating Bacillus anthracis (1877), the Tuberculosis bacillus (1882) and Vibrio cholerae (1883) and for his development of Koch's postulates. He was awarded the Nobel Prize in Physiology or Medicine in 1905 for his tuberculosis findings. Koch is one of the founders of microbiology, inspiring such major figures as Paul Ehrlich and Gerhard Domagk. [163]

U.S. Civil War Edit

In the American Civil War (1861–65), as was typical of the 19th century, more soldiers died of disease than in battle, and even larger numbers were temporarily incapacitated by wounds, disease and accidents. [167] Conditions were poor in the Confederacy, where doctors and medical supplies were in short supply. [168] The war had a dramatic long-term impact on medicine in the U.S., from surgical technique to hospitals to nursing and to research facilities. Weapon development -particularly the appearance of Springfield Model 1861, mass-produced and much more accurate than muskets led to generals underestimating the risks of long range rifle fire risks exemplified in the death of John Sedgwick and the disastrous Pickett's Charge. The rifles could shatter bone forcing amputation and longer ranges meant casualties were sometimes not quickly found. Evacuation of the wounded from Second Battle of Bull Run took a week. [169] As in earlier wars, untreated casualties sometimes survived unexpectedly due to maggots debriding the wound -an observation which led to the surgical use of maggots -still a useful method in the absence of effective antibiotics.

The hygiene of the training and field camps was poor, especially at the beginning of the war when men who had seldom been far from home were brought together for training with thousands of strangers. First came epidemics of the childhood diseases of chicken pox, mumps, whooping cough, and, especially, measles. Operations in the South meant a dangerous and new disease environment, bringing diarrhea, dysentery, typhoid fever, and malaria. There were no antibiotics, so the surgeons prescribed coffee, whiskey, and quinine. Harsh weather, bad water, inadequate shelter in winter quarters, poor policing of camps, and dirty camp hospitals took their toll. [170]

This was a common scenario in wars from time immemorial, and conditions faced by the Confederate army were even worse. The Union responded by building army hospitals in every state. What was different in the Union was the emergence of skilled, well-funded medical organizers who took proactive action, especially in the much enlarged United States Army Medical Department, [171] and the United States Sanitary Commission, a new private agency. [172] Numerous other new agencies also targeted the medical and morale needs of soldiers, including the United States Christian Commission as well as smaller private agencies. [173]

The U.S. Army learned many lessons and in August 1886, it established the Hospital Corps.

Statistical methods Edit

A major breakthrough in epidemiology came with the introduction of statistical maps and graphs. They allowed careful analysis of seasonality issues in disease incidents, and the maps allowed public health officials to identify critical loci for the dissemination of disease. John Snow in London developed the methods. In 1849, he observed that the symptoms of cholera, which had already claimed around 500 lives within a month, were vomiting and diarrhoea. He concluded that the source of contamination must be through ingestion, rather than inhalation as was previously thought. It was this insight that resulted in the removal of The Pump On Broad Street, after which deaths from cholera plummeted afterwards. English nurse Florence Nightingale pioneered analysis of large amounts of statistical data, using graphs and tables, regarding the condition of thousands of patients in the Crimean War to evaluate the efficacy of hospital services. Her methods proved convincing and led to reforms in military and civilian hospitals, usually with the full support of the government. [174] [175] [176]

By the late 19th and early 20th century English statisticians led by Francis Galton, Karl Pearson and Ronald Fisher developed the mathematical tools such as correlations and hypothesis tests that made possible much more sophisticated analysis of statistical data. [177]

During the U.S. Civil War the Sanitary Commission collected enormous amounts of statistical data, and opened up the problems of storing information for fast access and mechanically searching for data patterns. The pioneer was John Shaw Billings (1838–1913). A senior surgeon in the war, Billings built the Library of the Surgeon General's Office (now the National Library of Medicine), the centerpiece of modern medical information systems. [178] Billings figured out how to mechanically analyze medical and demographic data by turning facts into numbers and punching the numbers onto cardboard cards that could be sorted and counted by machine. The applications were developed by his assistant Herman Hollerith Hollerith invented the punch card and counter-sorter system that dominated statistical data manipulation until the 1970s. Hollerith's company became International Business Machines (IBM) in 1911. [179]

Worldwide dissemination Edit

United States Edit

Johns Hopkins Hospital, founded in 1889, originated several modern medical practices, including residency and rounds.

Japan Edit

European ideas of modern medicine were spread widely through the world by medical missionaries, and the dissemination of textbooks. Japanese elites enthusiastically embraced Western medicine after the Meiji Restoration of the 1860s. However they had been prepared by their knowledge of the Dutch and German medicine, for they had some contact with Europe through the Dutch. Highly influential was the 1765 edition of Hendrik van Deventer's pioneer work Nieuw Ligt ("A New Light") on Japanese obstetrics, especially on Katakura Kakuryo's publication in 1799 of Sanka Hatsumo ("Enlightenment of Obstetrics"). [180] [181] A cadre of Japanese physicians began to interact with Dutch doctors, who introduced smallpox vaccinations. By 1820 Japanese ranpô medical practitioners not only translated Dutch medical texts, they integrated their readings with clinical diagnoses. These men became leaders of the modernization of medicine in their country. They broke from Japanese traditions of closed medical fraternities and adopted the European approach of an open community of collaboration based on expertise in the latest scientific methods. [182]

Kitasato Shibasaburō (1853–1931) studied bacteriology in Germany under Robert Koch. In 1891 he founded the Institute of Infectious Diseases in Tokyo, which introduced the study of bacteriology to Japan. He and French researcher Alexandre Yersin went to Hong Kong in 1894, where Kitasato confirmed Yersin's discovery that the bacterium Yersinia pestis is the agent of the plague. In 1897 he isolated and described the organism that caused dysentery. He became the first dean of medicine at Keio University, and the first president of the Japan Medical Association. [183] [184]

Japanese physicians immediately recognized the values of X-Rays. They were able to purchase the equipment locally from the Shimadzu Company, which developed, manufactured, marketed, and distributed X-Ray machines after 1900. [185] Japan not only adopted German methods of public health in the home islands, but implemented them in its colonies, especially Korea and Taiwan, and after 1931 in Manchuria. [186] A heavy investment in sanitation resulted in a dramatic increase of life expectancy. [187]

Psychiatry Edit

Until the nineteenth century, the care of the insane was largely a communal and family responsibility rather than a medical one. The vast majority of the mentally ill were treated in domestic contexts with only the most unmanageable or burdensome likely to be institutionally confined. [188] This situation was transformed radically from the late eighteenth century as, amid changing cultural conceptions of madness, a new-found optimism in the curability of insanity within the asylum setting emerged. [189] Increasingly, lunacy was perceived less as a physiological condition than as a mental and moral one [190] to which the correct response was persuasion, aimed at inculcating internal restraint, rather than external coercion. [191] This new therapeutic sensibility, referred to as moral treatment, was epitomised in French physician Philippe Pinel's quasi-mythological unchaining of the lunatics of the Bicêtre Hospital in Paris [192] and realised in an institutional setting with the foundation in 1796 of the Quaker-run York Retreat in England. [23]

From the early nineteenth century, as lay-led lunacy reform movements gained in influence, [193] ever more state governments in the West extended their authority and responsibility over the mentally ill. [194] Small-scale asylums, conceived as instruments to reshape both the mind and behaviour of the disturbed, [195] proliferated across these regions. [196] By the 1830s, moral treatment, together with the asylum itself, became increasingly medicalised [197] and asylum doctors began to establish a distinct medical identity with the establishment in the 1840s of associations for their members in France, Germany, the United Kingdom and America, together with the founding of medico-psychological journals. [23] Medical optimism in the capacity of the asylum to cure insanity soured by the close of the nineteenth century as the growth of the asylum population far outstripped that of the general population. [a] [198] Processes of long-term institutional segregation, allowing for the psychiatric conceptualisation of the natural course of mental illness, supported the perspective that the insane were a distinct population, subject to mental pathologies stemming from specific medical causes. [195] As degeneration theory grew in influence from the mid-nineteenth century, [199] heredity was seen as the central causal element in chronic mental illness, [200] and, with national asylum systems overcrowded and insanity apparently undergoing an inexorable rise, the focus of psychiatric therapeutics shifted from a concern with treating the individual to maintaining the racial and biological health of national populations. [201]

Emil Kraepelin (1856–1926) introduced new medical categories of mental illness, which eventually came into psychiatric usage despite their basis in behavior rather than pathology or underlying cause. Shell shock among frontline soldiers exposed to heavy artillery bombardment was first diagnosed by British Army doctors in 1915. By 1916, similar symptoms were also noted in soldiers not exposed to explosive shocks, leading to questions as to whether the disorder was physical or psychiatric. [202] In the 1920s surrealist opposition to psychiatry was expressed in a number of surrealist publications. In the 1930s several controversial medical practices were introduced including inducing seizures (by electroshock, insulin or other drugs) or cutting parts of the brain apart (leucotomy or lobotomy). Both came into widespread use by psychiatry, but there were grave concerns and much opposition on grounds of basic morality, harmful effects, or misuse. [203]

In the 1950s new psychiatric drugs, notably the antipsychotic chlorpromazine, were designed in laboratories and slowly came into preferred use. Although often accepted as an advance in some ways, there was some opposition, due to serious adverse effects such as tardive dyskinesia. Patients often opposed psychiatry and refused or stopped taking the drugs when not subject to psychiatric control. There was also increasing opposition to the use of psychiatric hospitals, and attempts to move people back into the community on a collaborative user-led group approach ("therapeutic communities") not controlled by psychiatry. Campaigns against masturbation were done in the Victorian era and elsewhere. Lobotomy was used until the 1970s to treat schizophrenia. This was denounced by the anti-psychiatric movement in the 1960s and later.

Twentieth-century warfare and medicine Edit

The ABO blood group system was discovered in 1901, and the Rhesus blood group system in 1937, facilitating blood transfusion.

During the 19th century, large-scale wars were attended with medics and mobile hospital units which developed advanced techniques for healing massive injuries and controlling infections rampant in battlefield conditions. During the Mexican Revolution (1910–1920), General Pancho Villa organized hospital trains for wounded soldiers. Boxcars marked Servicio Sanitario ("sanitary service") were re-purposed as surgical operating theaters and areas for recuperation, and staffed by up to 40 Mexican and U.S. physicians. Severely wounded soldiers were shuttled back to base hospitals. [204] Canadian physician Norman Bethune, M.D. developed a mobile blood-transfusion service for frontline operations in the Spanish Civil War (1936–1939), but ironically, he himself died of blood poisoning. [205] Thousands of scarred troops provided the need for improved prosthetic limbs and expanded techniques in plastic surgery or reconstructive surgery. Those practices were combined to broaden cosmetic surgery and other forms of elective surgery.

During the second World War, Alexis Carrel and Henry Dakin developed the Carrel-Dakin method of treating wounds with an irrigation, Dakin's solution, a germicide which helped prevent gangrene. [206]

The War spurred the usage of Roentgen's X-ray, and the electrocardiograph, for the monitoring of internal bodily functions. This was followed in the inter-war period by the development of the first anti-bacterial agents such as the sulpha antibiotics.

Public health Edit

Public health measures became particularly important during the 1918 flu pandemic, which killed at least 50 million people around the world. [207] It became an important case study in epidemiology. [208] Bristow shows there was a gendered response of health caregivers to the pandemic in the United States. Male doctors were unable to cure the patients, and they felt like failures. Women nurses also saw their patients die, but they took pride in their success in fulfilling their professional role of caring for, ministering, comforting, and easing the last hours of their patients, and helping the families of the patients cope as well. [209]

From 1917 to 1932, the American Red Cross moved into Europe with a battery of long-term child health projects. It built and operated hospitals and clinics, and organized antituberculosis and antityphus campaigns. A high priority involved child health programs such as clinics, better baby shows, playgrounds, fresh air camps, and courses for women on infant hygiene. Hundreds of U.S. doctors, nurses, and welfare professionals administered these programs, which aimed to reform the health of European youth and to reshape European public health and welfare along American lines. [210]

Second World War Edit

The advances in medicine made a dramatic difference for Allied troops, while the Germans and especially the Japanese and Chinese suffered from a severe lack of newer medicines, techniques and facilities. Harrison finds that the chances of recovery for a badly wounded British infantryman were as much as 25 times better than in the First World War. The reason was that:

"By 1944 most casualties were receiving treatment within hours of wounding, due to the increased mobility of field hospitals and the extensive use of aeroplanes as ambulances. The care of the sick and wounded had also been revolutionized by new medical technologies, such as active immunization against tetanus, sulphonamide drugs, and penicillin." [211]

Nazi and Japanese medical research Edit

Unethical human subject research, and killing of patients with disabilities, peaked during the Nazi era, with Nazi human experimentation and Aktion T4 during the Holocaust as the most significant examples. Many of the details of these and related events were the focus of the Doctors' Trial. Subsequently, principles of medical ethics, such as the Nuremberg Code, were introduced to prevent a recurrence of such atrocities. [212] After 1937, the Japanese Army established programs of biological warfare in China. In Unit 731, Japanese doctors and research scientists conducted large numbers of vivisections and experiments on human beings, mostly Chinese victims. [213]

Malaria Edit

Starting in World War II, DDT was used as insecticide to combat insect vectors carrying malaria, which was endemic in most tropical regions of the world. [214] The first goal was to protect soldiers, but it was widely adopted as a public health device. In Liberia, for example, the United States had large military operations during the war and the U.S. Public Health Service began the use of DDT for indoor residual spraying (IRS) and as a larvicide, with the goal of controlling malaria in Monrovia, the Liberian capital. In the early 1950s, the project was expanded to nearby villages. In 1953, the World Health Organization (WHO) launched an antimalaria program in parts of Liberia as a pilot project to determine the feasibility of malaria eradication in tropical Africa. However these projects encountered a spate of difficulties that foreshadowed the general retreat from malaria eradication efforts across tropical Africa by the mid-1960s. [215]

Post-World War II Edit

The World Health Organization was founded in 1948 as a United Nations agency to improve global health. In most of the world, life expectancy has improved since then, and was about 67 years as of 2010 [update] , and well above 80 years in some countries. Eradication of infectious diseases is an international effort, and several new vaccines have been developed during the post-war years, against infections such as measles, mumps, several strains of influenza and human papilloma virus. The long-known vaccine against Smallpox finally eradicated the disease in the 1970s, and Rinderpest was wiped out in 2011. Eradication of polio is underway. Tissue culture is important for development of vaccines. Though the early success of antiviral vaccines and antibacterial drugs, antiviral drugs were not introduced until the 1970s. Through the WHO, the international community has developed a response protocol against epidemics, displayed during the SARS epidemic in 2003, the Influenza A virus subtype H5N1 from 2004, the Ebola virus epidemic in West Africa and onwards.

As infectious diseases have become less lethal, and the most common causes of death in developed countries are now tumors and cardiovascular diseases, these conditions have received increased attention in medical research. Tobacco smoking as a cause of lung cancer was first researched in the 1920s, but was not widely supported by publications until the 1950s. Cancer treatment has been developed with radiotherapy, chemotherapy and surgical oncology.

Oral rehydration therapy has been extensively used since the 1970s to treat cholera and other diarrhea-inducing infections.

The sexual revolution included taboo-breaking research in human sexuality such as the 1948 and 1953 Kinsey reports, invention of hormonal contraception, and the normalization of abortion and homosexuality in many countries. Family planning has promoted a demographic transition in most of the world. With threatening sexually transmitted infections, not least HIV, use of barrier contraception has become imperative. The struggle against HIV has improved antiretroviral treatments.

X-ray imaging was the first kind of medical imaging, and later ultrasonic imaging, CT scanning, MR scanning and other imaging methods became available.

Genetics have advanced with the discovery of the DNA molecule, genetic mapping and gene therapy. Stem cell research took off in the 2000s (decade), with stem cell therapy as a promising method.

Evidence-based medicine is a modern concept, not introduced to literature until the 1990s.

Prosthetics have improved. In 1958, Arne Larsson in Sweden became the first patient to depend on an artificial cardiac pacemaker. He died in 2001 at age 86, having outlived its inventor, the surgeon, and 26 pacemakers. Lightweight materials as well as neural prosthetics emerged in the end of the 20th century.

Modern surgery Edit

Cardiac surgery was revolutionized in 1948 as open-heart surgery was introduced for the first time since 1925.

In 1954 Joseph Murray, J. Hartwell Harrison and others accomplished the first kidney transplantation. Transplantations of other organs, such as heart, liver and pancreas, were also introduced during the later 20th century. The first partial face transplant was performed in 2005, and the first full one in 2010. By the end of the 20th century, microtechnology had been used to create tiny robotic devices to assist microsurgery using micro-video and fiber-optic cameras to view internal tissues during surgery with minimally invasive practices. [216]

Laparoscopic surgery was broadly introduced in the 1990s. Natural orifice surgery has followed. Remote surgery is another recent development, with the transatlantic Lindbergh operation in 2001 as a groundbreaking example.

Before You Start

Try Google! Type in everything you can remember about the book — as in, “picture book rabbi animals advice yiddish” — and scroll through the results. (That’s a real-life example of a book a patron was asking for: It Could Always Be Worse by Margot Zemach.)

You can also try googling one key detail you remember from a book. One of our librarians solved a book mystery by searching “USS You-Know-Who” — the name of a boat in the story that the patron happened to remember. (Another real-life example: She Flew No Flags by Joan Manley.)


Parts of northern Syria are known as Western Kurdistan (Kurdish: Rojavayê Kurdistanê ‎) or simply Rojava ( / ˌ r oʊ ʒ ə ˈ v ɑː / ROH -zhə- VAH Kurdish: [roʒɑˈvɑ] "the West") among Kurds, [50] [9] [51] one of the four parts of Greater Kurdistan. [52] The name "Rojava" was thus associated with a Kurdish identity of the administration. As the region expanded and increasingly included areas dominated by non-Kurdish groups, most importantly Arabs, "Rojava" was used less and less by the administration in hopes of deethnicising its appearance and making it more acceptable to other ethnicities. [53] Regardless, the polity continued to be called "Rojava" by locals and international observers, [11] [54] [12] [55] with journalist Metin Gurcan noting that "the concept of Rojava [had become] a brand gaining global recognition" by 2019. [54]

The territory around Jazira province of northeastern Syria is called Gozarto (Classical Syriac: ܓܙܪܬܐ ‎, romanized: Gozarto), part of the historical Assyrian homeland, by Syriac-Assyrians. [56] The area has also been nicknamed Federal Northern Syria, and the democratic confederalist autonomous areas of northern Syria. [9]

The first name of the local government for the Kurdish-dominated areas in Afrin District, Ayn al-Arab District (Kobanî), and northern al-Hasakah Governorate was "Interim Transitional Administration", adopted in 2013. [9] After the three autonomous cantons were proclaimed in 2014, [57] PYD-governed territories were also nicknamed "the Autonomous Regions" [9] or "Democratic Autonomous Administration". [58] On 17 March 2016, northern Syria's administration self-declared the establishment of a federal system of government as the Democratic Federation of Rojava – Northern Syria (Kurdish: Federaliya Demokratîk a Rojava – Bakurê Sûriyê ‎ Arabic: الفدرالية الديمقراطية لروج آفا – شمال سوريا ‎, romanized: al-Fidirāliyya al-Dīmuqrāṭiyya li-Rūj ʾĀvā – Šamāl Suriyā Classical Syriac: ܦܕܪܐܠܝܘܬ݂ܐ ܕܝܡܩܪܐܛܝܬܐ ܠܓܙܪܬܐ ܒܓܪܒܝܐ ܕܣܘܪܝܐ ‎, romanized: Federaloyotho Demoqraṭoyto l'Gozarto b'Garbyo d'Suriya sometimes abbreviated as NSR). [9] [59] [60] [61] [62]

The updated December 2016 constitution of the polity uses the name Democratic Federation of Northern Syria (DFNS) (Kurdish: Federaliya Demokratîk a Bakûrê Sûriyê ‎ Arabic: الفدرالية الديمقراطية لشمال سوريا ‎, romanized: al-Fidirāliyya al-Dīmuqrāṭiyya li-Šamāl Suriyā Classical Syriac: ܦܕܪܐܠܝܘܬ݂ܐ ܕܝܡܩܪܐܛܝܬܐ ܕܓܪܒܝ ܣܘܪܝܐ ‎, romanized: Federaloyotho Demoqraṭoyto d'Garbay Suriya). [63] [64] [65] [66]

Since 6 September 2018, the Syrian Democratic Council has adopted a new name for the region, naming it the Autonomous Administration of North and East Syria (NES) (Kurdish: Rêveberiya Xweser a Bakur û Rojhilatê Sûriyeyê ‎ Arabic: الإدارة الذاتية لشمال وشرق سوريا ‎ Classical Syriac: ܡܕܰܒܪܳܢܘܬ݂ܳܐ ܝܳܬ݂ܰܝܬܳܐ ܠܓܰܪܒܝܳܐ ܘܡܰܕܢܚܳܐ ܕܣܘܪܝܰܐ ‎, romanized: Mdabronuṯo Yoṯayto l-Garbyo w-Madnḥyo d-Suriya Turkish: Kuzey ve Doğu Suriye Özerk Yönetimi) also sometimes translated into English as the "Self-Administration of North and East Syria", encompassing the Euphrates, Afrin, and Jazira regions as well as the local civil councils in the regions of Raqqa, Manbij, Tabqa, and Deir ez-Zor. [67] [1] [68]

The region mainly lies to the west of the Tigris, to the east of the Euphrates, south of the Turkish border and borders Iraq to the southeast as well as the Iraqi Kurdistan Region to the northeast. The region is at latitude approximately 36°30' north and mostly consists of plains and low hills, however there are some mountains in the region such as Mount Abdulaziz as well as the western part of the Sinjar Mountain Range in the Jazira Region.

In terms of governorates of Syria, the region is formed from parts of the al-Hasakah, Raqqa, Deir ez-Zor and the Aleppo governorates.


Northern Syria is part of the Fertile Crescent, and includes archaeological sites dating to the Neolithic, such as Tell Halaf. In antiquity, the area was part of the Mitanni kingdom, its centre being the Khabur river valley in modern-day Jazira Region. It was then part of Assyria, with the last surviving Assyrian imperial records, from between 604 BC and 599 BC, were found in and around the Assyrian city of Dūr-Katlimmu. [69] Later it was ruled by different dynasties and empires – the Achaemenids of Iran, the Hellenistic empires who succeeded Alexander the Great, the Artaxiads of Armenia, [70] Rome, the Iranian Parthians and [71] Sasanians, [72] then by the Byzantines and successive Arab Islamic caliphates. In course of these regimes, different groups settled in northern Syria, often contributing to population shifts. Arabic tribes have been present in the area for millennia. [73] Under the Hellenistic Seleucid Empire (312–63 BC), different tribal groups and mercenaries were settled in northern Syria as military colonists these included Arabs [74] and possibly Kurds. [75] [b] Jan Retso argued that Abai, an Arab settlement where the Seleucid king Antiochus VI Dionysus was raised, was located in northern Syria. [74] By the 3rd century, the Arab tribe of the Fahmids lived in northern Syria. [77]

By the 9th century, northern Syria was inhabited by a mixed population of Arabs, Assyrians, Kurds, Turkic groups, and others. Kurdish tribes in the area often operated as soldiers for hire, [76] and were still placed in specific military settlements in the northern Syrian mountains. [78] There existed a Kurdish elite of which Saladin, [79] the founder of the Ayyubid dynasty and the Emir of Masyaf in the 12th century were part of. [80] Under Saladin's rule, northern Syria experienced a mass immigration of Turkic groups who came into conflict with Kurdish tribes, resulting in clashes that wiped out several Kurdish communities. [81]

During the Ottoman Empire (1516–1922), large Kurdish-speaking tribal groups both settled in and were deported to areas of northern Syria from Anatolia. [82] [83] By the 18th century, five Kurdish tribes existed in northeastern Syria. [78] The demographics of this area underwent a huge shift in the early part of the 20th century. Some Circassian, Kurdish and Chechen tribes cooperated with the Ottoman (Turkish) authorities in the massacres of Armenian and Assyrian Christians in Upper Mesopotamia, between 1914 and 1920, with further attacks on unarmed fleeing civilians conducted by local Arab militias. [82] [84] [83] [85] Many Assyrians fled to Syria during the genocide and settled mainly in the Jazira area. [83] [86] [87] Starting in 1926, the region saw another immigration of Kurds following the failure of the Sheikh Said rebellion against the Turkish authorities. [88] While many of the Kurds in Syria have been there for centuries, [89] [80] [90] waves of Kurds fled their homes in Turkey and settled in Syrian Al-Jazira Province, where they were granted citizenship by the French Mandate authorities. [91] The number of Turkish Kurds settled in al-Jazira province during the 1920s was estimated at 20,000 people, out of 100,000 inhabitants, with the remainder of the population being Christians (Syriac, Armenian, Assyrian) and Arabs. [92] : 458

Syria's independence and rule of the Ba'ath Party

Following Syria's independence, policies of Arab nationalism and attempts at forced Arabization became widespread in the country's north, to a large part directed against the Kurdish population. [93] [94] The region received little investment or development from the central government and laws discriminated against Kurds owning property, driving cars, working in certain professions and forming political parties. [95] Property was routinely confiscated by government loansharks. After the Ba'ath Party seized power in the 1963 Syrian coup d'état, non-Arab languages were forbidden at Syrian public schools. This compromised the education of students belonging to minorities like Kurds, Turkmen, and Assyrians. [96] [97] Some groups like Armenians, Circassians, and Assyrians were able to compensate by establishing private schools, but Kurdish private schools were also banned. [94] [98] Northern Syrian hospitals lacked equipment for advanced treatment and instead patients had to be transferred outside the region. Numerous place names were arabized in the 1960s and 1970s. [97] In his report for the 12th session of the UN Human Rights Council titled Persecution and Discrimination against Kurdish Citizens in Syria, the United Nations High Commissioner for Human Rights held that "Successive Syrian governments continued to adopt a policy of ethnic discrimination and national persecution against Kurds, completely depriving them of their national, democratic and human rights – an integral part of human existence. The government imposed ethnically-based programs, regulations and exclusionary measures on various aspects of Kurds' lives – political, economic, social and cultural." [99] Kurdish cultural festivals like Newroz were effectively banned. [100]

In many instances, the Syrian government arbitrarily deprived ethnic Kurdish citizens of their citizenship. The largest such instance was a consequence of a census in 1962, which was conducted for exactly this purpose. 120,000 ethnic Kurdish citizens saw their citizenship arbitrarily taken away and became stateless. [94] [100] [101] This status was passed to the children of a "stateless" Kurdish father. [94] In 2010, the Human Rights Watch (HRW) estimated the number of such "stateless" Kurdish people in Syria at 300,000. [102] [103] In 1973, the Syrian authorities confiscated 750 square kilometres (290 square miles) of fertile agricultural land in Al-Hasakah Governorate, which was owned and cultivated by tens of thousands of Kurdish citizens, and gave it to Arab families brought in from other provinces. [99] [98] In 2007, in the Al-Hasakah Governorate, 600 square kilometres (230 square miles) around Al-Malikiyah were granted to Arab families, while tens of thousands of Kurdish inhabitants of the villages concerned were evicted. [99] These and other expropriations was part of the so-called "Arab Belt initiative" which aimed to change the demographic fabric of the resource-rich region. [94] Accordingly, relations between the Syrian government and the Syrian Kurdish population were tense. [104]

The response of northern Syrian parties and movements to the policies of Hafez al-Assad's Ba'athist government varied greatly. Some parties opted for resistance, whereas others such as the Kurdish Democratic Progressive Party [105] and the Assyrian Democratic Party [106] attempted to work within the system, hoping to bring about changes through soft pressure. [107] In general, parties that openly represented certain ethnic and religious minorities were not allowed to participate in elections, but their politicians were occasionally allowed to run as Independents. [108] Some Kurdish politicians won seats during the Syrian elections in 1990. [109] The government also recruited Kurdish officials, in particular as mayors, to ease ethnic relations. Regardless, northern Syrian ethnic groups remained deliberately underrepresented in the bureaucracy, and many Kurdish majority areas were run by Arab officials from other parts of the country. [108] Security and intelligence agencies worked hard to suppress dissidents, and most Kurdish parties remained underground movements. The government monitored, though generally allowed this "sub-state activity" because the northern minorities including the Kurds rarely caused unrest with the exception of the 2004 Qamishli riots. [108] The situation improved after the death of Hafez al-Assad and the election of his son, Bashar al-Assad, under whom the number of Kurdish officials grew. [110]

Despite the Ba'athist internal policies which officially suppressed a Kurdish identity, the Syrian government allowed the Kurdistan Workers' Party (PKK) to set up training camps from 1980. The PKK was a militant Kurdish group led by Abdullah Öcalan which was waging an insurgency against Turkey. Syria and Turkey were hostile toward each other at the time, resulting in the use of the PKK as proxy group. [108] [54] The party began to deeply influence the Syrian Kurdish population in the Afrin and Ayn al-Arab Districts, where it promoted Kurdish identity through music, clothing, popular culture, and social activities. In contrast, the PKK remained much less popular among Kurds in al-Hasakah Governorate, where other Kurdish parties maintained more influence. Many Syrian Kurds developed a long-lasting sympathy for the PKK, and a large number, possibly more than 10,000, joined its insurgency in Turkey. [108] A rapprochement between Syria and Turkey brought an end to this phase in 1998, when Öcalan and the PKK were formally expelled from northern Syria. Regardless, the PKK maintained a clandestine presence in the region. [108] [54]

In 2002, the PKK and allied groups organized the Kurdistan Communities Union (KCK) to implement Öcalan's ideas in various Middle Eastern countries. A KCK branch was also set up in Syria, led by Sofi Nureddin and known as "KCK-Rojava". In an attempt to outwardly distance the Syrian branch from the PKK, [54] the Democratic Union Party (PYD) was established as de facto Syrian "successor" of the PKK in 2003. [108] The "People's Protection Units" (YPG), a paramilitary wing of the PYD, was also founded during this time, but remained dormant. [111]

Establishment of de facto autonomy and war against ISIL

In 2011, a civil uprising erupted in Syria, prompting hasty government reforms. One of the issues addressed during this time was the status of Syria's stateless Kurds, as President Bashar al-Assad granted about 220,000 Kurds citizenship. [110] In course of the next months, the crisis in Syria escalated into a civil war. The armed Syrian opposition seized control of several regions, while security forces were overstretched. In mid-2012 the government responded to this development by withdrawing its military from three mainly Kurdish areas [112] [113] and leaving control to local militias. This has been described as an attempt by the Assad regime to keep the Kurdish population out of the initial civil uprising and civil war. [112]

Existing underground Kurdish political parties, namely the PYD and the Kurdish National Council (KNC), joined to form the Kurdish Supreme Committee (KSC) and the People's Protection Units (YPG) militia was reestablished to defend Kurdish-inhabited areas in northern Syria. In July 2012, the YPG established control in the towns of Kobanî, Amuda and Afrin, and the Kurdish Supreme Committee established a joint leadership council to administer the towns. Soon YPG also gained control of the cities of Al-Malikiyah, Ras al-Ayn, al-Darbasiyah, and al-Muabbada and parts of Hasakah and Qamishli. [114] [115] [116] Doing so, the YPG and its female wing, the Women's Protection Units (YPJ), mostly battled factions of the Free Syrian Army, and Islamist militias like the al-Nusra Front and Jabhat Ghuraba al-Sham. It also eclipsed rival Kurdish militias, [117] [112] and absorbed some government loyalist groups. [118] According to researcher Charles R. Lister, the government's withdrawal and concurrent rise of the PYD "raised many eyebrows", as the relationship between the two entities was "highly contentious" at the time. The PYD was known to oppose certain government policies, but had also strongly criticised the Syrian opposition. [116]

The Kurdish Supreme Committee was dissolved in 2013, when the PYD abandoned the alliance with the KNC and established the Movement for a Democratic Society (TEV-DEM) coalition with other political parties. [119] On 19 July 2013, the PYD announced that it had written a constitution for an "autonomous Syrian Kurdish region", and planned to hold referendum to approve the constitution in October 2013. Qamishli served as first de facto capital of the PYD-led governing body, [8] which was official called the "Interim Transitional Administration". [9] The announcement was widely denounced by both moderate as well as Islamist factions of the Syrian opposition. [8] In January 2014, three areas under TEV-DEM rule declared their autonomy as cantons (now Afrin Region, Jazira Region and Euphrates Region) and an interim constitution was approved. The Syrian opposition and even the Kurdish parties belonging to the KNC condemned this move, regarding the canton system as illegal, authoritarian, and supportive of the Syrian government. [57] The PYD countered that the constitution was open to review and amendment, and that the KNC had been consulted on its drafting beforehand. [120] From September 2014 to spring 2015, the YPG forces in Kobanî Canton, supported by some Free Syrian Army militias and leftist international and Kurdistan Workers' Party (PKK) volunteers, fought and finally repelled an assault by the Islamic State of Iraq and the Levant (ISIL) during the Siege of Kobanî, [121] and in the YPG's Tell Abyad offensive of summer of 2015, the regions of Jazira and Kobanî were connected. [122]

After the YPG victory over ISIL in Kobanî in March 2015, an alliance between YPG and the United States was formed, which greatly worried Turkey, because Turkey stated the YPG was a clone of the Kurdistan Workers' Party (PKK) which Turkey (and the U.S. and the E.U.) designate as terrorists. [112] In December 2015, the Syrian Democratic Council was created. On 17 March 2016, at a TEV-DEM-organized conference in Rmelan the establishment the Democratic Federation of Rojava – Northern Syria was declared in the areas they controlled in Northern Syria. [123] The declaration was quickly denounced by both the Syrian government and the National Coalition for Syrian Revolutionary and Opposition Forces. [59]

In March 2016, Hediya Yousef and Mansur Selum were elected co-chairpersons for the executive committee to organise a constitution for the region, to replace the 2014 constitution. [4] Yousef said the decision to set up a federal government was in large part driven by the expansion of territories captured from Islamic State: "Now, after the liberation of many areas, it requires us to go to a wider and more comprehensive system that can embrace all the developments in the area, that will also give rights to all the groups to represent themselves and to form their own administrations". [124] In July 2016, a draft for the new constitution was presented, based on the principles of the 2014 constitution, mentioning all ethnic groups living in Northern Syria and addressing their cultural, political and linguistic rights. [125] [126] The main political opposition to the constitution have been Kurdish nationalists, in particular the KNC, who have different ideological aspirations than the TEV-DEM coalition. [127] On 28 December 2016, after a meeting of the 151-member Syrian Democratic Council in Rmelan, a new constitution was resolved despite objections by 12 Kurdish parties, the region was renamed the Democratic Federation of Northern Syria, removing the name "Rojava". [128]

Turkish military operations and occupation

Since 2012, when the first YPG pockets appeared, Turkey had been alarmed by the presence of PKK-related forces at its southern border and grew concerned when the YPG entered into an alliance with the US to oppose ISIS forces in the region. [129] The Turkish government refused to allow aid to be sent to the YPG during the Siege of Kobanî. This led to the Kurdish riots, the breakdown of the 2013–2015 peace process in July 2015 and the renewal of armed conflict between the PKK and Turkish forces. According to the Turkish pro-government newspaper Daily Sabah, the YPG's parent organisation, the PYD, provided the PKK with militants, explosives, arms and ammunition. [130]

in August 2016, Turkey launched Operation Euphrates Shield to prevent the YPG-led Syrian Democratic Forces (SDF) from linking Afrin Canton (now Afrin Region) with the rest of Rojava and to capture Manbij from the SDF. Turkish and Turkish-backed Syrian rebel forces prevented the linking of Rojava's cantons and captured all settlements in Jarabulus previously under SDF control. [131] The SDF handed over part of the region to the Syrian government to act as a buffer zone against Turkey. [132] Manbij remained under SDF control.

In early 2018, Turkey launched Operation Olive Branch alongside Turkish-backed Free Syrian Army to capture the Kurdish-majority Afrin and oust the YPG/SDF from region. [133] Afrin Canton, a subdivision of the region, was occupied and over 100,000 civilians were displaced and relocated to Afrin Region's Shahba Canton which remained under SDF, then joint SDF-Syrian Arab Army (SAA) control. The remaining SDF forces later launched an ongoing insurgency against the Turkish and Turkish-backed Syrian rebel forces. [134]

In 2019, Turkey launched Operation Peace Spring against the SDF. On 9 October, the Turkish Air Force launched airstrikes on border towns. [135] On 6 October President Donald Trump had ordered United States troops to withdraw from northeastern Syria where they had been providing support to the SDF. [136] Journalists called the withdrawal "a serious betrayal to the Kurds" and "a catastrophic blow to US credibility as an ally and Washington's standing on the world stage" one journalist stated that "this was one of the worst US foreign policy disasters since the Iraq War". [137] [138] [139] [140] Turkish and Turkish-backed Syrian rebel forces captured 68 settlements, including Ras al-Ayn, Tell Abyad, Suluk, Mabrouka and Manajir during the 9-day operation before a 120-hour ceasefire was announced. [141] [142] [143] [144] [145] The operation was condemned by the international community, [146] and human rights violations by Turkish forces were reported. [147] Media outlets labelled the attack "no surprise" because Turkish president Erdoğan had for months warned that the presence of the YPG on the Turkish-Syrian border despite the Northern Syria Buffer Zone was unacceptable. [112] An unintended consequence of the attack was that it raised the worldwide popularity and legitimacy of the northeastern Syrian administration, and several PYD and YPG representatives became internationally known to an unprecedented degree. However, these events caused tensions within the KCK, as differences emerged between the PKK and PYD leadership. The PYD was determined to maintain the regional autonomy and hoped for a continued alliance with the United States. In contrast, the PKK central command was now willing to restart negotiations with Turkey, distrusted the United States, and emphasized the international success of its leftist ideology over the survival of Rojava as administrative entity. [54]

The political system of the region is based on its adopted constitution, officially titled "Charter of the Social Contract". [34] [148] The constitution was ratified on 9 January 2014 it provides that all residents of the region shall enjoy fundamental rights such as gender equality and freedom of religion. [34] It also provides for property rights. [149] The region's system of community government has direct democratic aspirations. [150]

A September 2015 report in The New York Times observed: [34]

"For a former diplomat like me, I found it confusing: I kept looking for a hierarchy, the singular leader, or signs of a government line, when, in fact, there was none there were just groups. There was none of that stifling obedience to the party, or the obsequious deference to the "big man"—a form of government all too evident just across the borders, in Turkey to the north, and the Kurdish regional government of Iraq to the south. The confident assertiveness of young people was striking.

However, a 2016 paper from Chatham House [151] stated that power is heavily centralized in the hands of the Democratic Union Party (PYD). Abdullah Öcalan, a Kurdistan Workers' Party (PKK) leader imprisoned in İmralı, Turkey, has become an iconic figure in the region whose libertarian socialist ideology has shaped the region's society and politics through the ruling TEV-DEM coalition, a political alliance including the PYD and a number of smaller parties. Before TEV-DEM, the region was governed by the Kurdish Supreme Committee, a coalition of the PYD and the Kurdish National Council (KNC), which was dissolved by the PYD in 2013. [152] [153] [34] [154] Besides the parties represented in TEV-DEM and the KNC, several other political groups operate in northern Syria. Several of these, such as the Kurdish National Alliance in Syria, [155] [156] the Democratic Conservative Party, [157] the Assyrian Democratic Party, [158] and others actively participate in governing the region.

The politics of the region has been described as having "libertarian transnational aspirations" influenced by the PKK's shift toward anarchism, but also includes various "tribal, ethno-sectarian, capitalist and patriarchal structures." [149] The region has a "co-governance" policy in which each position at each level of government in the region includes a "female equivalent of equal authority" to a male. [159] Similarly, there are aspirations for equal political representation of all ethno-religious components – Arabs, Kurds and Assyrians being the most sizeable ones. This has been compared this to the Lebanese confessionalist system, which is based on that country's major religions. [149] [160] [161] [162]

The PYD-led rule has triggered protests in various areas since they first captured territory. In 2019, residents of tens of villages in the eastern Deir ez-Zor Governorate demonstrated for two weeks, regarding the new regional leadership as Kurdish-dominated and non-inclusive, citing arrests of suspected ISIL members, looting of oil, lack of infrastructure as well as forced conscription into the SDF as reasons. The protests resulted in deaths and injuries. [163] It has been stated that the new political structures created in the region have been based on top-down structures, which have placed obstacles for the return of refugees, created dissent as well as a lack of trust between the SDF and the local population. [164]

Qamishli initially served as the de facto capital of the administration, [8] [125] but the area's governing body later relocated to Ayn Issa. [1]

Administrative divisions

Article 8 of the 2014 constitution stipulates that "All Cantons in the autonomous regions are founded on the principle of local self-government. Cantons may freely elect their representatives and representative bodies, and may pursue their rights insofar as it does not contravene the articles of the Charter." [148]

The cantons were later reorganized into regions with subordinate cantons/provinces, areas, districts and communes. The first communal elections in the region were held on 22 September 2017. 12,421 candidates competed for around 3,700 communal positions during the elections, which were organized by the region's High Electoral Commission. [165] [166] Elections for the councils of the Jazira Region, Euphrates Region and Afrin Region were held in December 2017. [16] Most of Afrin Region was occupied by Turkish-led forces in early 2018, though the administrative division continued to operate from Tell Rifaat which is under joint YPG-Syrian Army control. [67] [167] [168]

On 6 September 2018, during a meeting of the Syrian Democratic Council in Ayn Issa, a new name for the region was adopted, the "Autonomous Administration of North and East Syria", encompassing the Euphrates, Afrin, and Jazira regions as well as the local civil councils in the regions of Raqqa, Manbij, Tabqa, and Deir ez-Zor. During the meeting, a 70-member "General Council for the Autonomous Administration of North and East Syria" was formed. [67] [1] [68]


In December 2015, during a meeting of the region's representatives in Al-Malikiyah, the Syrian Democratic Council (SDC) was established to serve as the political representative of the Syrian Democratic Forces. [169] The co-leaders selected to lead the SDC at its founding were prominent human rights activist Haytham Manna and TEV-DEM Executive Board member Îlham Ehmed. [170] [171] The SDC appoints an Executive Council which deal with the economy, agriculture, natural resources, and foreign affairs. [172] General elections were planned for 2014 and 2018, [172] but this was postponed due to fighting.


Under the rule of the Ba'ath Party, school education consisted of only Arabic language public schools, supplemented by Assyrian private confessional schools. [173] In 2015, the region's administration introduced primary education in the native language (either Kurdish or Arabic) and mandatory bilingual education (Kurdish and Arabic) for public schools, [174] [175] [176] with English as a mandatory third language. [177] There are ongoing disagreements and negotiations over curriculums with the Syrian central government, [178] [179] which generally still pays the teachers in public schools. [174] [180] [181] [182]

In August 2016, the Ourhi Centre was founded by the Assyrian community in the city of Qamishli, to educate teachers in order to make Syriac-Aramaic an additional language in public schools in Jazira Region, [183] which then started in the 2016/17 academic year. [179] According to the region's Education Committee, in 2016/2017 "three curriculums have replaced the old one, to include teaching in three languages: Kurdish, Arabic and Syriac." [184] In August 2017 Galenos Yousef Issa of the Ourhi Centre announced that the Syriac curriculum would be expanded to grade 6, which earlier had been limited to grade 3, with teachers being assigned to Syriac schools in Al-Hasakah, Al-Qahtaniyah and Al-Malikiyah. [185] [186] At the start of the academic year 2018–2019, the curricula in Kurdish and Arabic had been expanded to grades 1–12 and Syriac to grades 1–9. "Jineology" classes had also been introduced. [187] In general, schools are encouraged to teach the administration's "uptopian doctrine" which promotes diversity, democracy, and the ideas of Abdullah Öcalan. [31] [188] Local reactions to the changes to the school system and curriculum were mixed. While many praised the new system because it encouraged tolerance and allowed Kurds and other minorities to be taught in their own languages, [31] others have criticised it as de facto compulsory indoctrination. [189]

The federal, regional and local administrations in the region put much emphasis on promoting libraries and educational centers, to facilitate learning and social and artistic activities. Examples are the Nahawand Center for Developing Children's Talents in Amuda (est. 2015) and the Rodî û Perwîn Library in Kobani (May 2016). [190]

For Assyrian private confessional schools there had at first been no changes. [179] [191] However, in August 2018 it was reported that the region's authorities was trying to implement its own Syriac curriculum in private Christian schools that have been continuing to use an Arabic curriculum with limited Syriac classes approved by the Assad regime and originally developed by Syrian Education Ministry in cooperation with Christian clergy in the 1950s. The threatening of the closure of schools not complying with this resulted in protests erupting in Qamishli. [192] [193] [194] A deal was later reached in September 2018 between the region's authorities and the local Syriac Orthodox archbishopric, where the two first grades in these schools would learn the region's Syriac curriculum and grades three to six would continue to learn the Damascus approved curriculum. [195] [196]

Higher education

While there was no institution of tertiary education on the territory of the region at the onset of the Syrian Civil War, an increasing number of such institutions have been established by the regional administrations in the region since.

  • In September 2014, the Mesopotamian Social Sciences Academy in Qamishli started classes. [34] More such academies designed under a libertarian socialist academic philosophy and concept are in the process of founding or planning. [197]
  • In August 2015, the traditionally-designed University of Afrin in Afrin started teaching, with initial programs in literature, engineering and economics, including institutes for medicine, topographic engineering, music and theater, business administration and the Kurdish language. [198]
  • In July 2016, Jazira Canton Board of Education started the University of Rojava in Qamishli, with faculties for Medicine, Engineering, Sciences, and Arts and Humanities. Programs taught include health, oil, computer and agricultural engineering physics, chemistry, history, psychology, geography, mathematics and primary school teaching and Kurdish literature. [190][199] Its language of instruction is Kurdish, and with an agreement with Paris 8 University in France for cooperation, the university opened registration for students in the academic year 2016–2017. [200]
  • In August 2016 Jazira Canton police forces took control of the remaining parts of Hasakah city, which included the Hasakah campus of the Arabic-language Al-Furat University, and with mutual agreement the institution continues to be operated under the authority of the Damascus government's Ministry of Higher Education.


Incorporating the Universal Declaration of Human Rights, the International Covenant on Civil and Political Rights, the International Covenant on Economic, Social and Cultural Rights, as well as other internationally recognized human rights conventions, the 2014 Constitution of North and East Syria guarantees freedom of speech and freedom of the press. As a result, a diverse media landscape has developed in the region, [201] [202] in each of the Kurdish, Arabic, Syriac-Aramaic and Turkish languages of the land, as well as in English, and media outlets frequently use more than one language. Among the most prominent media in the region are Hawar News Agency and ARA News agencies and websites as well as TV outlets Rojava Kurdistan TV, Ronahî TV, and the bimonthly magazine Nudem. A landscape of local newspapers and radio stations has developed. However, media agencies often face economic pressure, as was demonstrated by the closure of news website Welati in May 2016. [203] In addition, the autonomous regions have imposed some limits on press freedom, for example forcing the press to get work permits. These can be cancelled, thereby curtailing the ability of certain press agencies to operate. However, the extent of these restricions differed greatly from area to area. By 2016, Kobani Canton was the least restrictive, followed by Jazira Canton which closely monitored and occasionally regulated press activity. [204] Afrin Canton was the most restrictive, and many local reporters operated anonymously. [205]

Political extremism in the context of the Syrian Civil War can put media outlets under pressure for example in April 2016 the premises of Arta FM ("the first, and only, independent radio station staffed and broadcast by Syrians inside Syria") in Amuda was threatened and burned down by unidentified assailants. [206] [207] In December 2018 the Rojava Information Center was established. [208] During the Turkish military operation in Afrin, the KDP-affiliated Iraqi Kurdish Rudaw Media Network was also banned from reporting in the region. [209] On 2 September 2019, the Iraqi Kurdistan-based Kurdistan 24 network had its license to work in the region, with drawn and had its offices confiscated by Rojava authorities. [210]

International media and journalists operate with few restrictions in the region, one of the only regions in Syria where they can operate with some degree of freedom. [202] This has led to several international media reports regarding the region, including major TV documentaries like BBC documentary (2014): Rojava: Syria's Secret Revolution or Sky1 documentary (2016): Rojava – The Fight Against ISIS.

Internet connections in the region are often slow due to inadequate infrastructure. Internet lines are operated by Syrian Telecom, which as of January 2017 is working on a major extension of the fibre optic cable network in southern Jazira Region. [211]

The arts

After the establishment of the de facto autonomous region, the Center of Art and Democratic Culture, located in Jazira Region, has become a venue for aspiring artists who showcase their work. [212] [213] Among major cultural events in the region is the annual Festival of Theater in March/April as well as the Rojava Short Story Festival in June, both in the city of Qamishli, and the Afrin Short Film Festival in April. [214]

The Jazira Region is a major wheat and cotton producer and has a considerable oil industry. The Euphrates Region suffered most destruction of the three regions and has huge challenges in reconstruction, and has recently seen some greenhouse agriculture construction. The Afrin Region has had a traditional specialization on olive oil including Aleppo soap made from it, and had drawn much industrial production from the nearby city of Aleppo due to the fighting in Aleppo city from 2012 to 2016. Price controls are managed by local committees, which can set the price of basic goods such as food and medical goods. [215]

It has been theorized that the Assad government had deliberately underdeveloped parts of Northern Syria in order to Arabize the region and make secession attempts less likely. [216] During the Syrian Civil War, the infrastructure of the region on average experienced less destruction than other parts of Syria. In May 2016, Ahmed Yousef, head of the Economic Body and chairman of Afrin University, stated that at the time, the economic output of the region (including agriculture, industry and oil) accounted for about 55% of Syria's gross domestic product. [217] In 2014, the Syrian government was still paying some state employees, [218] but fewer than before. [219] However, the administration of the region stated that "none of our projects are financed by the regime". [220]

At first, there were no direct or indirect taxes on people or businesses in the region instead, the administration raised money mainly through tariffs and selling oil and other natural resources. [221] [215] However, in July 2017, it was reported that the administration in the Jazira Region had started to collect income tax to provide for public services in the region. [222] In May 2016, The Wall Street Journal reported that traders in Syria experience the region as "the one place where they aren't forced to pay bribes." [223]

The main sources of revenue for the autonomous region have been presented as: 1. Public properties such as grain silos and oil and gas in the Jazira Region, 2. Local taxation and customs fees taken at the border crossings, 3. Service delivery, 4. Remittances from Iraq and Turkey, and 5. Local donations. In 2015, the autonomous administration shared information about the region's finances where its 2014 revenue was about 3 billion Syrian Pounds (≈5.8 million USD) of which 50% was spent on "self-defense and protection", 18% for the Jazira Canton (now Jazira Region), 8.5% for the Kobani Canton (now Euphrates Region), 8.5% for the Afrin Canton (now Afrin Region), 15% for the "Internal Committee" and any remainder was a reserve for the next year. [58] The AANES has by far the highest average salaries and standard of living throughout Syria, with salaries being twice as large as in regime controlled Syira, following the collapse of the Syrian Pound the AANES doubled salaries to maintain inflation, and allow for good wages. The AANES still faces challenges with distribution, food security, and healthcare. [224] [225] [226] [227]

External economic relations

Oil and food production is substantial, [172] so they are important exports. Agricultural products include sheep, grain and cotton. Important imports are consumer goods and auto parts. [228] Trade with Turkey and access to humanitarian and military aid is difficult due to a blockade by Turkey. [229] Turkey does not allow business people or goods to cross its border. [230] The blockade from adjacent territories held by Turkey and ISIL, and partially also the KRG, temporarily caused heavy distortions of relative prices in Jazira Region and Euphrates Region (while separate, Afrin Region borders government-controlled territory since February 2016) for example in Jazira Region and Euphrates Region, through 2016 petrol cost only half as much as bottled water. [231]

The Semalka Border Crossing with Iraqi Kurdistan had been intermittently closed by the Kurdistan Regional Government (KRG), but has been open permanently since June 2016, [232] [233] and along with the establishment of a corridor to Syrian government controlled territory in April 2017, [234] economic exchange has increasingly normalized. Further, in May 2017 in northern Iraq, the Popular Mobilization Forces fighting ISIL cleared a corridor connecting the autonomous region and Iraqi government-controlled territory. [235] [236] [237]

Economy policy framework

The autonomous region is ruled by a coalition which bases its policy ambitions to a large extent on the libertarian socialist ideology of Abdullah Öcalan and have been described as pursuing a model of economy that blends co-operative and private enterprise. [238] In 2012, the PYD launched what it called the "Social Economy Plan", later renamed the "People's Economy Plan" (PEP). [239] Private property and entrepreneurship are protected under the principle of "ownership by use". Dr. Dara Kurdaxi, a regional official, has stated: "The method in Rojava is not so much against private property, but rather has the goal of putting private property in the service of all the peoples who live in Rojava." [240] Communes and co-operatives have been established to provide essentials. [241] Co-operatives account for a large proportion of agricultural production and are active in construction, factories, energy production, livestock, pistachio and roasted seeds, and public markets. [238] Several hundred instances of collective farming occurred across towns and villages in the region, with communes consisting of approximately 20–35 people. [242] According to the region's "Ministry of Economics", approximately three-quarters of all property has been placed under community ownership and a third of production has been transferred to direct management by workers' councils. [243]

Legal system

Syrian civil laws are valid in the region if they do not conflict with the Constitution of the autonomous region. One example for amendment is personal status law, which in Syria is based on Sharia [244] and applied by Sharia Courts, [245] while the secular autonomous region proclaims absolute equality of women under the law, allowing civil marriage and banning forced marriage, polygamy [246] [247] and underage marriage. [248] [29]

A new criminal justice approach was implemented that emphasizes restoration over retribution. [249] The death penalty was abolished. [250] Prisons house mostly people charged with terrorist activity related to ISIL and other extremist groups. [251] A September 2015 report of Amnesty International stated that 400 people were incarcerated by the region's authorities and criticized deficiencies in due process of the judicial system of the region. [252] [34] [253]

The justice system in the region is influenced by Abdullah Öcalan's libertarian socialist ideology. At the local level, citizens create Peace and Consensus Committees, which make group decisions on minor criminal cases and disputes as well as in separate committees resolve issues of specific concern to women's rights like domestic violence and marriage. At the regional level, citizens (who need not be trained jurists) are elected by the regional People's Councils to serve on seven-member People's Courts. At the next level are four Appeals Courts, composed of trained jurists. The court of last resort is the Regional Court, which serves the region as a whole. Separate from this system, the Constitutional Court renders decisions on compatibility of acts of government and legal proceedings with the constitution of the region (called the Social Contract). [250]

Policing and security

Policing in the region is performed by the Asayish armed formation. Asayish was established on 25 July 2013 to fill the gap of security when the Syrian security forces withdrew. [254] Under the Constitution of North and East Syria, policing is a competence of the regions. The Asayish forces of the regions are composed of 26 official bureaus that aim to provide security and solutions to social problems. The six main units of Asayish are Checkpoints Administration, Anti-Terror Forces Command (HAT), Intelligence Directorate, Organized Crime Directorate, Traffic Directorate and Treasury Directorate. 218 Asayish centers were established and 385 checkpoints with 10 Asayish members in each checkpoint were set up. 105 Asayish offices provide security against ISIL on the frontlines across Northern Syria. Larger cities have general directorates responsible for all aspects of security including road controls. Each region has a HAT command, and each Asayish center organizes itself autonomously. [254]

Throughout the region, the municipal Civilian Defense Forces (HPC) [255] and the regional Self-Defense Forces (HXP) [256] also serve local-level security. In Jazira Region, the Asayish are further complemented by the Assyrian Sutoro police force, which is organized in every area with Assyrian population, provides security and solutions to social problems in collaboration with other Asayish units. [254] The Khabour Guards and Nattoreh, though not police units, also have a presence in the area, providing security in towns along the Khabur River. The Bethnahrain Women's Protection Forces also maintain a police branch. In the areas taken from ISIL during the Raqqa campaign, the Raqqa Internal Security Forces and Manbij Internal Security Forces operate as police forces. Deir ez-Zor also maintain an Internal Security Forces unit.


The main military force of the region is the Syrian Democratic Forces, an alliance of Syrian rebel groups formed in 2015. The SDF is led by the Kurdish majority People's Protection Units (Yekîneyên Parastina Gel, YPG). The YPG was founded by the PYD after the 2004 Qamishli clashes, but was first active in the Syrian Civil War. [257] There is also the Syriac Military Council (MFS), an Assyrian militia associated with the Syriac Union Party. There are also Free Syrian Army groups in the alliance such as Jaysh al-Thuwar and the Northern Democratic Brigade, tribal militias like the Arab Al-Sanadid Forces, and municipal military councils in the Shahba region, like the Manbij Military Council, the Al-Bab Military Council or the Jarablus Military Council.

The Self-Defence Forces (HXP) is a territorial defense militia and the only conscript armed force in the region. HXP is locally recruited to garrison their municipal area and is under the responsibility and command of the respective regions of the NES. Occasionally, HXP units have supported the YPG, and SDF in general, during combat operations against ISIL outside their own municipality and region.

Human rights

In the course of the Syrian Civil War, including the years 2014 and 2015, reports by Human Rights Watch (HRW) and Amnesty International stated that militias associated with the autonomous region were committing war crimes, in particular members of the People's Protection Units (YPG). [258] [259] The reports from 2014 include reports of arbitrary arrests and torture, other reports include the use of child soldiers. [260] [261] [262] After the report, the YPG publicly accepted the deficiencies [260] and in October 2015 the YPG demobilized 21 minors from the military service in its ranks. [263] Reports have been comprehensively debated and contested by both the YPG and other human rights organizations. [264] [265] In 2018, HRW again accused the YPG of recruiting minors. The YPG responded that if 16- and 17-year-olds are hired, the relatives are notified, but do not have to consent, and the minors are kept away from combat zones. [266] Since September 2015, the YPG have received human rights training from Geneva Call and other international organizations. [267]

The region's civil government has been hailed in international media for human rights advancement in particular in the legal system, concerning women's rights, ethnic minority rights, freedom of Speech and Press and for hosting inbound refugees. [268] [269] [270] [271] The political agenda of "trying to break the honor-based religious and tribal rules that confine women" is controversial in conservative quarters of society. [248] Conscription into the Self-Defence Forces (HXP) has been called a human rights violation by those who call the region's institutions illegitimate. [272]

Some persistent issues in the region concern ethnic minority rights. One issue of contention is the consequence of Baathist Syrian government's exprorpiation of land from Kurdish owners and settling of tribal Arabs there in 1973 and 2007, [99] [94] [98] There have been calls to expel the settlers and return the land to its previous owners, which has led the political leadership of the region to press the Syrian government for a comprehensive solution. [273]

During the ongoing Syrian Civil War, organizations such as the Turkish government, [274] Amnesty International [275] and the Middle East Observer [276] [277] have stated that SDF was forcibly displacing inhabitants of captured areas with predominantly Arab population such as Tell Abyad. These displacements were considered attempts at ethnic cleansing. [278] However, the head of the Syrian Observatory for Human Rights rebutted these reports [279] and the UN Independent International Commission of Inquiry find no evidence of YPG or SDF forces committing ethnic cleansing in order to change the demographic composition of territories under their control. [39]

The demographics of the region have historically been highly diverse, with several major shifts in regard to which groups form majorities or minorities in the last centuries. [c] The Al-Hasakah Governorate historically been the domain of nomad and sedentary Arabs. [284] Most of the Kurdish population in the area have immigrated from Turkey during the 20th century. [285] One major shift in modern times was in the early part of the 20th century due to the Assyrian and Armenian genocides, when many Assyrians and Armenians fled to Syria from Turkey. In the 1920s after the failed Kurdish rebellions in Kemalist Turkey, there was a large influx of Kurds to Syria's northeast, called "Jazira province" at the time. It is estimated that 25,000 Kurds fled at this time to Syria, under French Mandate authorities, who encouraged their immigration, [286] and granted them Syrian citizenship. [287] Consequently, the French official reports show the existence of at most 45 Kurdish villages in Jazira prior to 1927. A new wave of refugees arrived in 1929. [288] The mandatory authorities continued to encourage Kurdish immigration into Syria, and by 1939, the villages numbered between 700 and 800. [288] Another account by Sir John Hope Simpson estimated the number of Kurds in Jazira province at 20,000 out of 100,000 people at the end of 1930. [92] : 556 The number of Kurds continued to grow and the French geographers Fevret and Gibert estimated that in 1953 out of the total 146,000 inhabitants of Jazira, agriculturalist Kurds made up 60,000 (41%), nomad Arabs 50,000 (34%), and a quarter of the population were Christians. [284]

Under the French Mandate of Syria, newly arriving Kurds were granted citizenship by French Mandate authorities [91] and enjoyed considerable rights as the French Mandate authority encouraged minority autonomy as part of a divide and rule strategy and recruited heavily from the Kurds and other minority groups, such as Alawite and Druze, for its local armed forces. [289] The last significant wave of Kurdish incoming migration from Turkey happened between 1945 and 1961 which strongly contributed to the growth of al-Hasakah Governorate's population from 240,000 to 305,000 between 1954 and 1961. [290] In addition to the demographic changes brought about by the Kurdish immigration from Turkey, the Syrian government initiated Arabization policy. Therefore, 4000 Arab families from areas flooded by the Tabqa Dam in Raqqa and Aleppo were resettled in new village in al-Hasakah Governorate. [93] [94]

Another shift in modern times was the Baath policy of settling additional Arab population in northern Syria, while displacing local Kurds. [93] [94] Most recently, during the Syrian Civil War, many refugees have fled to the north of the country. Some ethnic Arab citizens from Iraq have fled to northern Syria as well. [271] [291] [292] However, as of January 2018, only two million people are estimated to remain in the area under the region's administration with estimates of around half a million people emigrating since the beginning of the civil war, to a large degree because of the economic hardships the region has faced during the war. [7] As result of the civil war, estimates as to the ethnic composition of northern Syria vary widely, ranging from claims about a Kurdish majority and Arab minority to claims about Kurds being a small minority [293] Al Jazeera stated in October 2019 that just 10 percent of the 4.5 million inhabitants of northern and northeastern Syria were Kurds. [294]

Ethnic groups

Two ethnic groups have a significant presence throughout Northern Syria:

  • Kurds are an ethnic group[295] living in northeastern and northwestern Syria, culturally and linguistically classified among the Iranian peoples. [296][297][298] Many Kurds consider themselves descended from the ancient Iranian people of the Medes, [299] using a calendar dating from 612 B.C., when the Assyrian capital of Nineveh was conquered by the Medes. [300] Kurds formed 55% of the 2010 population of what now is both Jazira Region and Euphrates Region. [216] During the Syrian civil war, many Kurds who had lived elsewhere in Syria fled back to their traditional lands in Northern Syria. [citation needed]
  • Arabs are an ethnic group[301][302][303][304][305] or ethnolinguistic group[306][307][308] living throughout Northern Syria, mainly defined by Arabic as their first language. They encompass Bedouin tribes who trace their ancestry to the Arabian Peninsula as well as arabized indigenous peoples and preexisting Arab groups. [309][310] Arabs form the majority or plurality in some parts of Northern Syria, in particular in the southern parts of the Jazira Region, in Tell Abyad District and in Azaz District. While in Shahba region the term Arab is mainly used to denote arabized Kurds [216] and arabized Syrians, [309] in Euphrates Region and in Jazira Region it mainly denotes ethnic Arab Bedouin populations. [310]

Two ethnic groups have a significant presence in certain regions of Northern Syria:

  • Assyrians are an ethnic group. [311] Their presence in Syria is in the Jazira Region of the autonomous region, particularly in the urban areas (Qamishli, al-Hasakah, Ras al-Ayn, Al-Malikiyah, Al-Qahtaniyah), in the northeastern corner and in villages along the Khabur River in the Tell Tamer area. They traditionally speak varieties of Northeastern Neo-Aramaic, a Semitic language. [312] There are many Assyrians among recent refugees to Northern Syria, fleeing Islamist violence elsewhere in Syria back to their traditional lands. [313] In the secular polyethnic political climate of the region, the Dawronoye modernization movement has a growing influence on Assyrian identity in the 21st century. [30]
  • Turkmen are an ethnic group with a major presence in the area between Afrin Region and Euphrates Region, where they form regional majorities in the countryside from Azaz and Mare' to Jarabulus, and a minor presence in Afrin Region and Euphrates Region.

There are also smaller minorities of Armenians throughout Northern Syria as well as Chechens in Ras al-Ayn.


Regarding the status of different languages in the autonomous region, its "Social Contract" stipulates that "all languages in Northern Syria are equal in all areas of life, including social, educational, cultural, and administrative dealings. Every people shall organize its life and manage its affairs using its mother tongue." [314] In practice, Arabic and Kurmanji are predominantly used across all areas and for most official documents, with Syriac being mainly used in the Jazira Region with some usage across all areas while Turkish and Circassian are also used in the region of Manbij.

The four main languages spoken in Northern Syria are the following, and are from three different language families:

    (in Northern Kurdish dialect), a Northwestern Iranian language[315][316] from the Indo-European language family. in the North Mesopotamian Arabic dialect (Modern Standard Arabic in education and writing), a Central Semitic language from the Semitic language family mainly in the Turoyo and Assyrian Neo-Aramaic varieties (mainly Classical Syriac in education and writing), Northwest Semitic languages from the Semitic language family. (in Syrian Turkmen dialect), from the Turkic language family.

For these four languages, three different scripts are in use in Northern Syria:

  • The Latin alphabet for Kurdish, Turkish and Turoyo
  • The Arabic alphabet (abjad) for Arabic
  • The Syriac alphabet for Classical Syriac, Turoyo and Assyrian Neo-Aramaic


Most ethnic Kurdish and Arab people in Northern Syria adhere to Sunni Islam, while ethnic Assyrian people generally are Syriac Orthodox, Chaldean Catholic, Syriac Catholic or adherents of the Assyrian Church of the East. There are also adherents to other religions, such as Yazidism. [317] The dominant PYD party and the political administration in the region are decidedly secular. [30] [318]

Population centres

This list includes all cities and towns in the region with more than 10,000 inhabitants. The population figures are given according to the 2004 Syrian census. [319]
Cities highlighted in light grey are partially under the civil control of the Syrian government. [320] [321] [322] [323]

English Name Kurdish Name Arabic Name Syriac Name Turkish Name Population Region
Raqqa Reqa الرقة ܪܩܗ Rakka 220,488 Raqqa
Al-Hasakah Hesîçe الحسكة ܚܣܟܗ Haseke 188,160 Jazira
Qamishli Qamişlo القامشلي ܩܡܫܠܐ Kamışlı 184,231 Jazira
Manbij Menbîç منبج ܡܒܘܓ Münbiç 99,497 Manbij
Tabqa Tebqa الطبقة ܛܒܩܗ Tabka 69,425 Tabqa
Kobani Kobanî عين العرب ܟܘܒܐܢܝ Arappınar 44,821 Euphrates
Hajin Hecîn هجين‎ ܗܓܝܢ 37,935 Deir Ez-Zor
Amuda Amûdê عامودا ܥܐܡܘܕܐ Amudiye 26,821 Jazira
Al-Malikiyah Dêrika Hemko المالكية ܕܪܝܟ Deyrik 26,311 Jazira
Gharanij غرانيج ܓܪܐܢܝܓ 23,009 Deir Ez-Zor
Abu Hamam Ebû Hemam أبو حمام‎ ܐܒܘ ܚܡܐܡ 21,947 Deir Ez-Zor
Tell Rifaat Arfêd تل رفعت ܬܠ ܪܦܥܬ Tel Rıfat 20,514 Afrin
Al-Shaafah الشعفة ܫܥܦܗ 18,956 Deir Ez-Zor
Al-Qahtaniyah Tirbespî القحطانية ܩܒܪ̈ܐ ܚܘܪ̈ܐ Kubur el Bid 16,946 Jazira
Al-Mansurah المنصورة‎ ܡܢܨܘܪܗ 16,158 Tabqa [324]
Al-Shaddadah Şeddadê الشدادي ܫܕܐܕܝ Şaddadi 15,806 Jazira
Al-Muabbada Girkê Legê المعبدة ܡܥܒܕܗ Muabbada 15,759 Jazira
Al-Kishkiyah الكشكية ܟܫܟܝܗ 14,979 Deir Ez-Zor
Al-Sabaa wa Arbain Seba û Erbîyn السبعة وأربعين ܣܒܥܗ ܘܐܪܒܥܝܢ El Seba ve Arbayn 14,177 Jazira
Rmelan Rimêlan رميلان ܪܡܝܠܐܢ Rimelan 11,500 Jazira
Al-Baghuz Fawqani Baxoz الباغوز فوقاني‎ ܒܐܓܘܙ ܦܘܩܐܢܝ 10,649 Deir Ez-Zor


Healthcare is organized through the region's "Health and Environment Authority" and through sub-region and canton-level Health Committees. [325] [326] [327] [328] Independent organizations providing healthcare in the region include the Kurdish Red Crescent, the Syrian American Medical Society, the Free Burma Rangers and Doctors Without Borders. The 2019 Turkish offensive left thousands of people in the region without access to basic necessities as the majority of international aid groups withdrew during the violence. [329] [330]

Relations with the Syrian government

Currently, the relations of the region to the Damascus government are determined by the context of the Syrian civil war. The Constitution of Syria and the Constitution of North and East Syria are legally incompatible with respect to legislative and executive authority. In the military realm, combat between the People's Protection Units (YPG) and Syrian government forces has been rare, in the most instances some of the territory still controlled by the Syrian government in Qamishli and al-Hasakah has been lost to the YPG. In some military campaigns, in particular in northern Aleppo governate and in al-Hasakah, YPG and Syrian government forces have tacitly cooperated against Islamist forces, the Islamic State of Iraq and the Levant (ISIL) and others. [20]

The region does not state to pursue full independence but rather autonomy within a federal and democratic Syria. [37] In July 2016, Constituent Assembly co-chair Hediya Yousef formulated the region's approach towards Syria as follows: [ citation needed ]

We believe that a federal system is ideal form of governance for Syria. We see that in many parts of the world, a federal framework enables people to live peacefully and freely within territorial borders. The people of Syria can also live freely in Syria. We will not allow for Syria to be divided all we want is the democratization of Syria its citizens must live in peace, and enjoy and cherish the ethnic diversity of the national groups inhabiting the country.

In March 2015, the Syrian Information Minister announced that his government considered recognizing the Kurdish autonomy "within the law and constitution". [331] While the region's administration is not invited to the Geneva III peace talks on Syria, [332] or any of the earlier talks, Russia in particular calls for the region's inclusion and does to some degree carry the region's positions into the talks, as documented in Russia's May 2016 draft for a new constitution for Syria. [333] In October 2016, there were reports of a Russian initiative for federalization with a focus on northern Syria, which at its core called to turn the existing institutions of the region into legitimate institutions of Syria also reported was its rejection for the time being by the Syrian government. [273] The Damascus ruling elite is split over the question whether the new model in the region can work in parallel and converge with the Syrian government, for the benefit of both, or if the agenda should be to centralize again all power at the end of the civil war, necessitating preparation for ultimate confrontation with the region's institutions. [334]

An analysis released in June 2017 described the region's "relationship with the regime fraught but functional" and a "semi-cooperative dynamic". [335] In late September 2017, Syria's Foreign Minister said that Damascus would consider granting Kurds more autonomy in the region once ISIL is defeated. [336]

On 13 October 2019, the SDF announced that it had reached an agreement with the Syrian Army which allowed the latter to enter the SDF-held cities of Manbij and Kobani in order to dissuade a Turkish attack on those cities as part of the cross-border offensive by Turkish and Turkish-backed Syrian rebels. [337] The Syrian Army also deployed in the north of Syria together with the SDF along the Syrian-Turkish border and entered into several SDF-held cities such as Ayn Issa and Tell Tamer. [338] [339] Following the creation of the Second Northern Syria Buffer Zone the SDF stated that it was ready to merge with the Syrian Army if when a political settlement between the Syrian government and the SDF is achieved. [340]

Kurdish question

The region's dominant political party, the Democratic Union Party (PYD), is a member organisation of the Kurdistan Communities Union (KCK) organization however, the other KCK member organisations in the neighbouring states (Turkey, Iran and Iraq) with Kurdish minorities are either outlawed (Turkish Kurdistan, Iranian Kurdistan) or politically marginal with respect to other Kurdish parties (Iraq). Expressions of sympathy for Syrian Kurds have been numerous among Kurds in Turkey. [341] During the Siege of Kobanî, some ethnic Kurdish citizens of Turkey crossed the border and volunteered in the defense of the town. [342] [343]

The region's relationship with the Kurdistan Regional Government in Iraq is complicated. One context is that the governing party there, the Kurdistan Democratic Party (KDP), views itself and its affiliated Kurdish parties in other countries as a more conservative and nationalist alternative and competitor to the KCK political agenda and blueprint in general. [37] The political system of Iraqi Kurdistan [344] stands in stark contrast to the region's system. Like the KCK umbrella organization, the PYD has some anti-nationalist ideological leanings while having Kurdish nationalist factions as well. [345] They have traditionally been opposed by the Iraqi-Kurdish KDP-sponsored Kurdish National Council in Syria with more clear Kurdish nationalist leanings. [346]

International relations

The region's role in the international arena is comprehensive military cooperation of its militias under the Syrian Democratic Forces (SDF) umbrella with the United States and the international (US-led) coalition against the Islamic State of Iraq and the Levant. [347] [348] In a public statement in March 2016, the day after the declaration of the regions autonomy, U.S. Defense Secretary Ashton Carter praised the People's Protection Units (YPG) militia as having "proven to be excellent partners of ours on the ground in fighting ISIL. We are grateful for that, and we intend to continue to do that, recognizing the complexities of their regional role." [349] Late October 2016, U.S. Army Lt. Gen. Stephen Townsend, the commander of the international Anti-ISIL-coalition, said that the SDF would lead the impending assault on Raqqa, ISIL's stronghold and capital, and that SDF commanders would plan the operation with advice from American and coalition troops. [350] At various times, the U.S. deployed U.S. troops embedded with the SDF to the border between the region and Turkey, in order to deter Turkish aggressions against the SDF. [351] [352] [353] [354] [355] In February 2018, the United States Department of Defense released a budget blueprint for 2019 with respect to the region, which included $300 million for the Syrian Democratic Forces (SDF) and $250 million for border security. [356] In April 2018, the President of France, Emmanuel Macron dispatched troops to Manbij and Rmelan in a bid to assist Syrian Democratic Forces (SDF) militias and in order to defuse tensions with Turkey. [357]

In the diplomatic field, the de facto autonomous region lacks any formal recognition. While there is comprehensive activity of reception of the region's representatives [358] [359] [360] [361] and appreciation [362] with a broad range of countries, only Russia has on occasion openly supported the region's political ambition of federalization of Syria in the international arena, [273] [333] while the U.S. does not. [363] [364] After peace talks between Syrian civil war parties in Astana in January 2017, Russia offered a draft for a future constitution of Syria, which would, among other things, change the "Syrian Arab Republic" into the "Republic of Syria", introduce decentralized authorities as well as elements of federalism like "association areas", strengthen the parliament at the cost of the presidency, and realize secularism by abolishing Islamic jurisprudence as a source of legislation. [365] [366] [367] [368] The region opened official representation offices in Moscow during 2016, [369] Stockholm, [370] Berlin, [371] Paris, [372] and The Hague. [373] A broad range of public voices in the U.S. and Europe have called for more formal recognition of the region. [270] [271] [374] [375] International cooperation has been in the field of educational and cultural institutions, like the cooperation agreement of Paris 8 University with the newly founded University of Rojava in Qamishli, [376] or planning for a French cultural centre in Amuda. [377] [378] [379]

Neighbouring Turkey is consistently hostile, which has been attributed to a perceived threat from the region's emergence, in that it would encourage activism for autonomy among Kurds in Turkey in the Kurdish–Turkish conflict. In this context, in particular the region's leading Democratic Union Party (PYD) and the YPG militia being members of the Kurdistan Communities Union (KCK) network of organisations, which also includes both political and military Kurdish organizations in Turkey itself, including the Kurdistan Workers' Party (PKK). Turkey's policy towards the region is based on an economic blockade, [270] persistent attempts of international isolation, [380] opposition to the cooperation between the American-led anti-ISIL coalition and the Syrian Democratic Forces, [381] and support of Islamist opposition fighters hostile to the autonomous region, [382] [383] [384] with some reports even including ISIL among these. [385] [386] [387] Turkey has on several occasions militarily attacked the region's territory and defence forces. [388] [389] [390] This has resulted in some expressions of international solidarity with the region. [d]

On 9 October 2019, Turkey launched an attack on northern Syria "to destroy the terror corridor" on the Turkish southern border, as president Erdogan put it, after US President Donald Trump abandoned his support. Subsequent media reports have speculated that the offensive would lead to the displacement of hundreds of thousands of people. [394]

In December 2019, an international conference hosted by the International Alliance for the Defence of Rights and Freedoms (AIDL) was held at the European Parliament which condemned the Turkish invasion of northeastern Syria, and called for the self-declared Autonomous Administration of North East Syria to be recognized and to be included in UN-led Constitutional Committee tasked to draft a new constitution for Syria. The official position of the European Union remained the same however, that the Autonomous Administration should be "respected" and included in talks while rejecting "any recognition in the national sense of the word" and that "the territorial integrity of Syria is fundamental". [395] [396]

Syrian Constitutional Committee

On 20 November 2019, a new Syrian Constitutional Committee began operating in order to discuss a new settlement and to draft a new constitution for Syria. [397] This committee comprises about 150 members. It includes representatives of the Syrian regime, opposition groups, and countries serving as guarantors of the process such as e.g. Russia. However, this committee has faced strong opposition from the Assad regime. 50 of the committee members represent the regime, and 50 members represent the opposition. The committee began its work in November 2019 in Geneva, under UN auspices. However, the Assad regime delegation left on the second day of the process. [397]

At a summit in October 2018, envoys from Russia, Turkey, France and Germany issued a joint statement affirming the need to respect territorial integrity of Syria as a whole. This forms one basis for their role as "guarantor nations." [397]

The second round of talks occurred around 25 November, but was not successful due to opposition from the Assad regime. [397] At the Astana Process meeting in December 2019, a UN official stated that in order for the third round of talks to proceed, co-chairs from the Assad regime and the opposition need to agree on an agenda. [397]

The committee has two co-chairs, Ahmad Kuzbari representing the Assad regime, and Hadi Albahra from the opposition. It is unclear if the third round of talks will proceed on a firm schedule, until the Assad regime provides its assent to participate. [397]

Accusations of human rights violations, war crimes and ethnic cleansing have been made against the YPG since the beginning of the Syrian civil war, such as in the take-over of the border town of Tal Abyad from the Islamic State of Iraq and the Levant (ISIL) and other operations. [26] Some of the accusations have come from Turkey and Turkish-backed Syrian militias and opposition groups in the region, while others have come from numerous Human Rights organizations, as well as western and regional journalists. [398] [399] [400] [401]

In March 2017 the "United Nations Independent International Commission of Inquiry on Syria" was unable to find evidence to substantiate claims about ethnic cleansing, stating:

“Though allegations of ‘ethnic cleansing’ continued to be received during the period under review, the Commission found no evidence to substantiate claims that YPG or SDF forces ever targeted Arab communities on the basis of ethnicity, nor that YPG cantonal authorities systematically sought to change the demographic composition of territories under their control through the commission of violations directed against any particular ethnic group,” [402] [403] [404]

However, Amnesty International have gone on their own fact-finding missions, stating that:

“By deliberately demolishing civilian homes, in some cases razing and burning entire villages, displacing their inhabitants with no justifiable military grounds, the Autonomous Administration is abusing its authority and brazenly flouting international humanitarian law, in attacks that amount to war crimes."

"In its fight against IS, the Autonomous Administration appears to be trampling all over the rights of civilians who are caught in the middle. We saw extensive displacement and destruction that did not occur as a result of fighting. This report uncovers clear evidence of a deliberate, co-ordinated campaign of collective punishment of civilians in villages previously captured by IS, or where a small minority were suspected of supporting the group.” [405]

The region has also been criticized extensively by various partisan and non-partisan sides over political authoritarianism. [120] A KDP-S politician accused the PYD of delivering him to the Assad regime, [406] as well as the YPG is accused of fighting alongside regime forces in the 2017 Aleppo offensive. [ citation needed ]

It has also been criticized for banning journalists, media outlets and political parties that are critical of the YPG narrative in areas under its control. [407] [408]

Elisha Barber

Updated: Gave book second go to page 200, improved quite a bit as magic finally comes into it. But I&aposm not loving it. And as there&aposs two more books to the story I don&apost think I want to continue.

I&aposm stopping at page 130. The book is just not giving me an reasons to continue. And quite a few reasons to stop. There&aposs no hook. Nothing to pull me in further. Nice historical details not enough. Been fairly gruesome so far. Updated: Gave book second go to page 200, improved quite a bit as magic finally comes into it. But I'm not loving it. And as there's two more books to the story I don't think I want to continue.

I'm stopping at page 130. The book is just not giving me an reasons to continue. And quite a few reasons to stop. There's no hook. Nothing to pull me in further. Nice historical details not enough. Been fairly gruesome so far. . more

As a teenager, I was obsessed with the medieval period. In recent years, it hasn&apost attracted me as much--so many books repeat the same themes and decades. This book reminded me of how awesome well-written medieval fiction can be, in part because it hit on another one of my major obsessions: healers. Usually they are utilized as handy side characters, patching up the hero when in need. Not so here. Ambrose explores the occupation of the medieval barber, a multitasking field that involves hair-cut As a teenager, I was obsessed with the medieval period. In recent years, it hasn't attracted me as much--so many books repeat the same themes and decades. This book reminded me of how awesome well-written medieval fiction can be, in part because it hit on another one of my major obsessions: healers. Usually they are utilized as handy side characters, patching up the hero when in need. Not so here. Ambrose explores the occupation of the medieval barber, a multitasking field that involves hair-cutting, beard-trimming, and all your down-and-dirty doctoring needs.

Elisha is a dark and gritty protagonist. He's not some squeaky-clean goody-two-shoes. He's a damaged man who shares a house with his brother and his wife, and hasn't spoken to either in two years. He tends to the medical needs of a street of brothels. He's closed off emotionally. However, his heart is in the right place, and he has a healer's touch and intuition.

There's a touch of realism to the events. It truly feels like Ambrose researched the medieval battlefield, the injuries, and the crude surgical methods of the time period. The magical element isn't all lights and glitter no, it's as down-and-dirty as the mud of the battlefield.

I immensely enjoyed the book. It just brings so many fabulous elements together--a medical lead character, an unglamorous and real setting, and a magical system that brings chaos and wonder to the plot. I definitely want to read more books in this series as they are released. . more

I was recommended ELISHA BARBER by a friend of mine, fellow reviewer Steve Caldwell, who sent me the first two novels with the first in audiobook CD form. I was doing a lot of driving during that time so I had time to soak in the ten hour storyline. I&aposm glad I did since I feel this is a really overlooked gem in the "gritty Medieval fantasy" collection that seems so popular right now due to Game of Thrones. It&aposs, simply put, about a Medieval barber (more surgeon than hair--though he does that too I was recommended ELISHA BARBER by a friend of mine, fellow reviewer Steve Caldwell, who sent me the first two novels with the first in audiobook CD form. I was doing a lot of driving during that time so I had time to soak in the ten hour storyline. I'm glad I did since I feel this is a really overlooked gem in the "gritty Medieval fantasy" collection that seems so popular right now due to Game of Thrones. It's, simply put, about a Medieval barber (more surgeon than hair--though he does that too) who gets dragooned into being a field medic due to a series of tragic events that get him arrested for his brother's death.

The books are perhaps the goriest stories ever written about a protagonist who is, at least for the most part, a pacifist. Large parts of the book are devoted to Elisha desperately trying to come up with ways to save the lives of patients who are in need of amputation or having their wounds sewn up. I won't lie to you, some of the scenes had me fast forwarding because they were so gruesome but really help sell this is a setting where violence isn't being glamorized. People die from infection and disemboweling rather than neat little sword strikes.

Elisha, himself, is a character who strangely reminds me of the Witcher's Geralt. Not in the context of being a badass--the two characters couldn't be more different in their combat capacity. Instead, they are the unusually empathetic individuals who hold cynical world-weary attitudes born from the fact they know they're from a barbaric time where superstition is valued over reason while hate is more powerful than love. It's as if someone managed to combine Geralt with Doctor Gregory House. The fact Elisha is a working-class hero who doesn't get any of the respect or wealth a educated physician possesses is also a note more toward Geralt than Gregory.

The most interesting parts of the book are Elisha's struggle to keep men alive in appalling conditions and you get a real sense of his ice-skating uphill. He is, after all, in the middle of a war and even if he patches the men up--they'll just be sent back to the front unless they lose a limb. Elisha is a bit TOO educated in how to treat wounds and I rolled my eyes a bit that he somehow learned stitching from a Arabic prostitute who used to work at a Middle Eastern hospital. Still, I liked the contrast between Elisha's attempts to minimize pain versus the use of the men as guinea pigs for the court physicians' experiments.

The book could have been entirely been about Elisha's suffering but there's actually a substantial plot about witchcraft, plots against the king, and a woman burned at the stake in front of Elisha's eyes who seemingly became an angel. I was less interested in this plot, especially as the witches seemed to be "do no wrong" good guys, but didn't hate it either. I'm also intrigued about the possibilities of Elisha becoming a magus himself since the book's title is "The Dark Apostle" while the next book is called "Elisha Magus."

The villains of the book are a bit too one-dimensionally evil for my tastes with the Physician and King being especially heinous [expletive]. Nevertheless, they served their purpose as embodying the privilege and casual cruelty of their stations. As Talisa the nurse said to Robb Stark, his father's death may be of the greatest importance to him but thousands of innocent men on both sides are paying the price for his actions. I also very much like the ambiguity surrounding the character of Bridgit as her own plans went in directions I did not expect.

There's some genuinely powerful moments throughout the book with the race to save his sister-in-law, the grim discovery his stillborn nephew has to be sawed out, the horrible discovery in the woodshed, and the punishment Elisha suffers for his midnight rendevouz with a woman above his station. I also felt catharsis at the climax when powerful forces went to town on the worst of the people surrounding Elisha. This is a book with a lot of great moments and they, by themselves, cause me to recommend it strongly.

Is it grimdark? Well, I think it's about as grimdark as Game of Thrones where people like Jon Snow are good and noble but they're surrounded by corruption they're mostly powerless to change. Elisha Barber is a decent man caught in a horrible situation and I enjoyed reading about his exploits. It's just I was more interested in Elisha Barber the surgeon than I was in Elisha Barber the magic-seeker.

History of Mental Illness Treatment


As one of the earliest forms of mental health treatment, trephination removed a small part of the skull using an auger, bore or saw. Dated from around 7,000 years ago, this practice was likely used to relieve headaches, mental illness or even the belief of demonic possession. Not much is known about the practice due to lack of evidence.

Bloodletting and Purging

Though this treatment gained prominence in the Western world beginning in the 1600s, it has its roots in ancient Greek medicine. Claudius Galen believed that disease and illness stemmed from imbalanced humors in the body. English physician Thomas Willis used Galen’s writings as a basis for this approach to treating mentally ill patients. He argued that “an internal biochemical relationship was behind mental disorders. Bleeding, purging, and even vomiting were thought to help correct those imbalances and help heal physical and mental illness,” according to Everyday Health. These tactics were used to treat more than mental illness, however: Countless diseases like diabetes, asthma, cancer, cholera, smallpox and stroke were likely to be treated with bloodletting using leeches or venesection during the same time period.

Isolation and Asylums

Isolation was the preferred treatment for mental illness beginning in medieval times, so it’s no surprise that insane asylums became widespread by the 17th century. These institutions were “places where people with mental disorders could be placed, allegedly for treatment, but also often to remove them from the view of their families and communities,” Everyday Health says. Overcrowding and poor sanitation were serious issues in asylums, which led to movements to improve care quality and awareness. At the time, the medical community often treated mental illness with physical methods. This is why brutal tactics like ice water baths and restraint were often used.

Insulin Coma Therapy

This treatment was introduced in 1927 and was used for several decades until the 1960s. In insulin coma therapy, physicians deliberately put the patient into a low blood sugar coma because they believed large fluctuations in insulin levels could alter the function of the brain. Insulin comas could last anywhere between one and four hours. Patients were given an insulin injection that caused their blood sugar to fall and the brain to lose consciousness. Risks included prolonged coma (in which the patient failed to respond to glucose), and the mortality rate varied between 1 and 10 percent. Electroconvulsive therapy was later introduced as a safer alternative to insulin coma therapy.

Metrazol Therapy

In metrazol therapy, physicians induced seizures using a stimulant medication. Seizures began roughly a minute after the patient received the injection and could result in fractured bones, torn muscles and other adverse effects. The therapy was usually administered several times a week. Metrazol was withdrawn from use by the FDA in 1982. While this treatment was dangerous and ineffective, seizure therapy was the precursor to electroconvulsive therapy (ECT), which is still used in some cases to treat severe depression, mania and catatonia.


This now-obsolete treatment won the Nobel Prize in Physiology and Medicine in 1949. It was designed to disrupt the circuits of the brain but came with serious risks. Popular during the 1940s and 1950s, lobotomies were always controversial and prescribed in psychiatric cases deemed severe. It consisted of surgically cutting or removing the connections between the prefrontal cortex and frontal lobes of the brain. The procedure could be completed in five minutes. Some patients experienced improvement of symptoms however, this was often at the cost of introducing other impairments. The procedure was largely discontinued after the mid-1950s with the introduction of the first psychiatric medications.

Hitler’s Teeth Reveal Nazi Dictator’s Cause of Death

In a new study, French scientists analyzed fragments of Adolf Hitler’s teeth to prove that he died in 1945, after taking cyanide and shooting himself in the head. The research, published in the European Journal of Internal Medicine in May 2018, seeks to end conspiracy theories about Adolf Hitler’s death through scientific analysis of the dictator’s teeth and skull.

“Our study proves that Hitler died in 1945,” lead study author Philippe Charlier told AFP. “The teeth are authentic, there is no possible doubt.”

Though it’s widely established that Hitler died in his bunker in Berlin, rumors of his escape abound. Their research proves that “he did not flee to Argentina in a submarine, he is not in a hidden base in Antarctica or on the dark side of the moon,” said Charlier.

In late April 1945, as Soviet forces stormed Berlin, Hitler made plans for his suicide, including testing SS-supplied cyanide pills on his Alsatian, Blondi, and dictating a final will and testament. Two days earlier, Mussolini had been shot by a firing squad and then publicly hung by his feet in a suburban square in Milan, Italy: A similar fate seemed inevitable.

Late on April 30, the bodies of Hitler and his new wife, Eva Braun, were found in the bunker, with a bullet hole in Hitler’s temple.

Adolf Hitler on a German WWII poster, 1943.

Galerie Bilderwelt/Getty Images

In April 2018, the English publication of the memoirs of a Russian interpreter revealed how she had been entrusted with a set of teeth in 1945, and tasked with cross-checking them against the dictator’s dental records: They matched, and have remained in Russian hands ever since, the Telegraph reported.

After months of negotiations, Russia’s FSB secret service and the Russian state archives gave the researchers permission to examine a skull fragment and bits of his teeth. The piece of skull had a hole on its left side, consistent with a bullet wound, with black charring around the edges. Though scientists weren’t allowed to take samples from the skull, they noted in the study, its shape seemed “totally comparable” to radiographies of Hitler’s skull taken a year before his death.

Gruesome pictures of the teeth published in the study show a jaw made mostly of metal. 𠇊t the moment of his death,” they wrote in the report, “Hitler had only four remaining teeth.” The few there are misshapen, brown at the base, and flecked with white tartar deposits.

The analysis corroborated frequently-cited claims that Hitler was a vegetarian, but could not conclusively prove whether he took cyanide before the gunshot. Bluish deposits on his false teeth, the researchers wrote, suggest a variety of different hypotheses𠅍id some chemical reaction take place between his fake teeth and the cyanide at the moment of death, during his cremation, or while the remains were buried?

Without taking samples for analysis, it’s hard to say for sure. “We didn’t know if he had used an ampule of cyanide to kill himself or whether it was a bullet in the head. It’s in all probability both,” Charlier said.

Either way, the study may help finally put tales of Hitler’s flight to rest, once and for all.

Watch the video: Ursprung der Technik - Pioniere der Medizin - Heilkunst im alten Rom