Published 15 December 2008, doi:10.1136/bmj.a2761
Cite this as: BMJ 2008;337:a2761

Analysis

Christmas 2008: Professional Considerations

Back to the future: emergency departments and ancient Greek warfare

¹ Manchester Royal Infirmary, Manchester M13 9WL

Warfare in ancient Greece and modern emergency departments have much in common, says Bernard A Foëx

Ancient Greek warfare, as depicted in the Iliad, focuses on the exploits of individual heroes such as Achilles and Ajax. The ordinary soldiers take second place in the narrative.

In the 6th and 5th centuries BC the armies fielded by the Greek city states against each other and against the invading Persians were characterised by the phalanx of hoplites: citizen soldiers, who paid for their own equipment. They were briefly drilled before a campaign but were in no way a professional army: the exception being Sparta. These armies were commanded by a "king" or a general. A small number of light infantry and cavalry also existed, usually stationed on the wings. The battle itself was generally decided by the discipline and the bravery of the hoplites and their general.

The end of the hoplites

The 4th century BC saw the emergence of other battle formations. Iphicrates defeated a Spartan hoplite phalanx using peltasts, light infantry armed with javelins, at the battle of Lechaeum in 390 BC. Their ability to out manoeuvre the heavily armed hoplites proved decisive. At the same time the northern Greeks developed a much more effective cavalry force than their southern rivals. At the battle of Leuctra (371 BC) the Theban commander Epaminondas used his Thessalian cavalry to great effect, routing the Spartan cavalry, which then hindered the formation of the Spartan phalanx. As Macedonia came to dominate the classical world under Philip and then Alexander, so cavalry increasingly proved decisive. The Macedonian phalanx still had to hold the line but it alone could no longer win the battle.

The successors and the Hellenistic period

After the death of Alexander in 323 BC the armies of the successors showed a much greater diversity of troops, with units drawn from all quarters of the ancient world. Their armies still contained troops fighting in the phalanx formation, but there were also units of light infantry, companion cavalry (heavy cavalry), Thracian cavalry, lancers, and horse archers from Parthia, as well as units of Indian elephants, all with their own distinctive battle formations and ways of fighting.

Evolution of the emergency department

Emergency medicine developed in mythical times around a few heroes whose feats have entered the legend of emergency medicine rather like Homer’s heroes. More recently, the historical record describes casualty departments under the command of one general, often an orthopaedic surgeon, staffed by citizen doctors (senior house officers) from various specialty rotations, briefly drilled at the start of a six month campaign. They were the phalanx and the battle was won or lost by their ability to hold the line—or cope. Occasionally cavalry appeared in the form of registrars from hospital specialties to engage particular enemies: a case of epiglottitis, for example.

As casualty departments became accident and emergency departments the army started to change. The generals, now specialists in their own right, not only commanded the army but also fought in the phalanx, as their predecessors the Spartan kings had done. In addition to the phalanx of citizen soldiers there emerged the specialist registrars: an elite, whose continual training was paid for by the deanery. Now the battle was largely won by their ability to cope.

The end of the hoplites (senior house officers)

With growing pressures on emergency departments, including the four hour target, the model of the hoplite phalanx was no longer adequate. As in Iphicrates’s time a new type of troop was needed, lighter armed and more manoeuvrable than the ponderous hoplite: the emergency nurse practitioner. As with the peltast, he or she could engage with large numbers of patients with minor injuries and put them to flight, leaving the phalanx of senior house officers and specialist registrars to engage the "major" and "resuscitation" cases.

The successor departments (the emergency care village)

Emergency departments now resemble the armies of the successors in the Hellenistic period. There is still the phalanx of trainees in foundation year 2, holding the line, and the elite units, the old style specialist registrars, veterans of many campaigns, trusted to make the decisive push or to stabilise a faltering phalanx. But there are also specialist troops, such as the specialty trainees in their third year doing paediatric modules, and the paediatric trained nurses, operating on one flank in the audiovisually separated paediatric area; the emergency nurse practitioners, who continue to operate largely independently, skirmishing in the minor injury unit. There are acute care common stem trainees and specialty trainees, deployed in "majors," and behind the front line there is the clinical decision unit. Increasingly, the "army" includes an advance guard: the primary care centre.

The generals (consultants)

What of the generals? In Homeric times they fought individual combats with selected enemies. Later they commanded armies, selecting the place and the time of battle and occasionally joining in the fighting at the front of the phalanx. With ever larger emergency departments there may now be several generals, each with a specific role: one might lead the paediatric area, another the resuscitation room. These generals will tend to be clinical decision makers. The overall strategic vision will still be needed. As with Alexander’s successors these generals must be strategists and warriors excelling in hand to hand combat, all at the same time.

King Pyrrhus of Epirus epitomised this dual role. According to Plutarch, "above all, although he exposed himself in personal combat and drove back all who encountered him, he kept throughout a complete grasp of the progress of the battle and never lost his presence of mind. He directed the action as though he were watching it from a distance, yet he was everywhere himself, and always managed to be at hand to support his troops wherever the pressure was greatest."¹

Back to the future

So emergency medicine and emergency departments have developed in much the same way as the armies of ancient Greece. Does this parallel give us clues to the future? The apotheosis of these armies was Alexander’s. With his armies he conquered the known world. His successors never matched his achievements and while they squabbled over his legacy another super power would emerge, insignificant in Alexander’s time: Rome.

Rome with its army of fanatical citizen soldiers would eventually dominate the ancient world. Its army was also based on infantry. In contrast to the hoplites, with their spears, the legionaries fought with an effective short sword (gladius) after first throwing javelins. Their great advantages over the Macedonians were their ability to fight over broken terrain and their confidence in their own ability, their ferocity or virtus. This they demonstrated at the Battle of Cynoscephalae (197 BC) when part of the Macedonian phalanx was outflanked and slaughtered. A generation later at the Battle of Pydna (168 BC) the result was the same once the phalanx’s deadly array of pikes had been disrupted by the uneven terrain.

What then is the threat to the "Hellenistic" emergency departments of today? Arguably it is the army of fanatical citizen providers of emergency care, who, according to the Department of Health’s NHS next stage review, may be able to provide urgent care out in the community around the clock.² With vast resources this primary care army may well sweep aside the smaller forces of highly skilled professionals, just as their predecessors did 2000 years ago.

Further reading Cameron C. Tyrant. London: Orion, 2008. Hanson VD. The wars of the ancient Greeks. London: Cassell, 1999. Keegan J. A history of warfare. London: Random House, 1993. Lendon JE. Soldiers and ghosts—a history of battle in classical antiquity. New Haven and London: Yale University Press, 2005. Sidebottom H. Ancient warfare—a very short introduction. Oxford: Oxford University Press, 2004. Van Wees H. Greek warfare—myths and realities. London: Duckworth, 2004.

Cite this as: BMJ 2008;337:2761

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The ideas for this article were prompted by reading Christian Cameron’s novel, Tyrant: a wonderful example of scholarship and imagination. I thank Hans van Wees for his helpful comments and the concept of armies of fanatical amateurs.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

1. Plutarch. Pyrrhus. In: The age of Alexander. London: Penguin, 1973:384-425.
2. Department of Health. NHS next stage review: our vision for primary and community care. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085937. 2008.

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