The History of Ambulances

Overview of the History of Ambulances
The term ambulance comes from the Latin word ambulare which means to walk or move about which is a reference to early medical care where patients were moved by lifting or wheeling. This history of ambulances begins in ancient times with the use of carts to transport incurable patients by force. Ambulances were first used for emergency transport in 1487 by the Spanish although the more proper term is ambulance wagon. The word ambulance originally meant a moving hospital which follows an army in its movements. Later this term was referred to as field hospitals where ambulance wagons delivered patients. Perhaps it is sad state of human affairs that the history of ambulances follow the history of warfare. Many of the advances in medical care occurred during war.

The History of Ambulances in the Early Years
During the Crusades of the 11th Century, the Knights of St John received instruction in first-aid treatment from Arab and Greek doctors. The Knights of St John then acted as the first emergency workers, treating soldiers on both sides of the war of the battlefield and bringing in the wounded to nearby tents for further treatment. The concept of ambulance service started in Europe with the Knights of St John, at the same time it had also become common practice for small rewards to be paid to soldiers who carried the wounded bodies of other soldiers in for medical treatment.

Any discussion of the history of ambulances should include a brief history of the Knights of St John. The Knights of St John are also known as the Knights Hospitalier or the Knights of Malta. The "Maltese Cross" which is often associated with emergency services derives its name from the cross that the Knights wore on their tunics. In addition, the "Red Cross" is also derived from this symbol.

The Knights of St John were founded in 1080 AS to provide care to the poor, sick and injured pilgrims in the Holy Land during the crusades. The Knights of St John were established as a holy order by the Pope along with the Knights Templar. The Knights Templar were dissolved in 1312 by the King of France and much of the wealth and land of the Templars' went to the Knights of St John.

The Knights of St John battled with Muslims during the crusades and wore black surcoats with white crosses. Eventually the Knights of St John divided into a military order and an order to care for the sick. The military order went on to become the protectors of the Mediterranean Sea and eventually were phased out. The medical order still exists today in several forms.

In 1792 the Surgeon-in-Chief of the French Grand Army, the Baron Dominiquie Larrey, created the first official army medical group in any army in the world. Trained attendants were equipped to move from field hospitals to render first aid and then return with the wounded back to the hospital using stretcher, carts, wagons or even carrying them.

The History of Ambulances in the American Revolutionary War
A great book written by Jack E. McCallum "Military Medicine" (published by ABC-CLIO, 2008) describes in great detail the nature of medicine during war from the United States point of view. Information here is used under a fair use policy.

At the start of the American Revolutionary War, there were approximately 3500 "Physicians" in the colonies. This is a broad definition for the term "Physician". Only about 200 had actual medical degrees (usually trained in Europe) and the rest were attendants or barbers. The concept of ambulance service did not exist and the technology for transporting the wounded from the battlefield had not changed much since the Knights of St John began the service.

Wounded solders were expected to die. This was a fact of war. At the Battle of Bunker Hill in June of 1775, General Horatio Gates left his wounded troops for up to 3 days. If the wounded survived and retrieved from the battlefield, they had to pay a pricey sum for their quarters while they received some sort of treatment.

The first act of mandating treatment for the wounded followed after the battle with the Massachusetts Provincial Congress mandated the establishment of military hospitals. Each regiment was required to find and fund quarters that could be used as a field hospital. Early medical care for the wounded was patterned after the British model but this was inconsistent even in the British army.

In 1776 common war diseases were rampant in the Continental Army. Such diseases were small pox, malnutrition, pneumonia, frostbite and dysentery. General George Washington petitioned the Continental Congress for a general medical corps. This was established in 1777 and set to serve an army of 20,000. Surgeons in the army medical corps were paid $1.66/day (approximately $20.00/day in 2007) which was considerably less than the lowest paid army quartermaster.

By 1781 the War Department was established and oversaw the medical corps. By the wars end, 1200 "Physicians" served the Continental Army but the death rate was still very high. Approximately 250,000 soldiers served in the Continental Army and 25,000 died in service. Of those, 6500 died in battle; 10,000 died in hospital and the rest died enroute. The wounded were transported in open carts with 25% of those dying from infection. The common treatment for leg fractures was amputation with about 50% of those patients dying.

After the war, the medical service was disbanded but because of the high mortality rate new medical schools were created in the United States and army personal were trained better to handle battlefield medical needs.

The History of Ambulances in the American Civil War
At the start of the ware the US Army at 16,000 soldiers and 114 physicians. After secession 8 surgeons and 29 assistant surgeons resigned to join the confederacy. Most surgeons were assigned to specific regiments. After the first four months of the war, the Union Army grew to 109,000 most of which geographically based regiments.

Each regimental commander was responsible for picking his medical staff. These were usually doctors and staff local to were the regiment was created. This gave the comfort to the soldiers that they would be treated by people they knew.

In the first few battles of the Civil War, regimental doctors set up aid stations with in a few hundred yards of the battle and raised a red flag so soldiers could find them. Frequently doctors would not release their patients to often better equipped and less crowded rear hospitals because of the desire to care for the "Local Boys" and the desire on the soldiers part to stay with their unit.

At the battle of Bull Run in July 1861 the Union Army suffered 2708 casualties. Many of the appointed stretcher bearers fled the field and the wounded were left for days. Those wounded who could walk, walked 27 miles back to Washington. Those who made it to aid stations were more often than not, worked on by physicians who had never operated on a patient before.

The Office Surgeon General had been created by the War Department prior to the start of the war. This was a first in the history of ambulances in the United states. Never before was there a cabinet position dedicated to the health of soldiers.

There were several aged and ineffective Surgeon Generals who were eventually replace by a 34 year old William A. Hammond in January of 1862.

William A Hammond, US Surgeon General 1862

Hammond created several innovations in military medical treatment. He is also considered the Father of Modern Ambulance Services. During his tenure as Surgeon General of the Army he implemented procedures to sanitize hospital camps. The concepts of bacterial infection would not be discovered till the years after the war but it was thought that cleaning up the hospitals would reduce deaths. Hammond was correct in his assumptions.

Hammond also removed from general service several drugs that were common place (but dangerous). Such drugs as mercury and arsenic were used to treat infection but ended up killing the patients. Army hospitals were usually set up in old buildings such as warehouses. The ventilation and light were insufficient for patient care. Hammond adopted the idea (from Europe) of a Pavilion type of hospital with large well lighted and ventilated spaces. This type of hospital design was in use well into the 1970's.

Hammond's greatest achievements to care for the wounded involved the transport of the wounded. The military command and control structure we re-worked and removed the responsibility to transport the wounded from line officers and placed that responsibility on the medical corps. A military occupational specialty (MOS) was created designating specific litter bearer and ambulance-wagon drivers. This MOS still exists in the military today.

Hammond also designed an superior ambulance-wagon. In the history of ambulances this was the first purpose built ambulance.

Hammond demanded (and got) one ambulance for every 150 soldiers and got two medical supply wagons for each regimental corps. His improved transportation system proved so good that at the battle of Antietam (September 1862) his stretcher bearers and ambulance-wagons had every one of the Union Army's 9420 wounded soldiers off the battlefield before the day ended. This was a remarkable feat in the early history of ambulances.

The History of Ambulances in the Post Civil-War Period
The first hospital based ambulance service began in the United States in 1865. This service started at the Commercial Hospital in Cincinnati, Ohio. In 1869 Bellevue Hospital in New York City started an ambulance service under the direction of Edward Dalton - a former Union Army surgeon. He believed that speed was king. The faster the service the better the patient outcome. His ambulance-wagons carried much of the equipment that was in vogue at the time. The equipment were splints, stomach pumps, morphine and brandy. Horse teams were standing by on-call and were responding within 30 seconds of being called.

The first ambulance was staffed by doctors from the hospital. The first were Drs. Duncan Lee and Robert Taylor. They are considered to be New York's first emergency responders. The service was extremely popular. In 1870 they responded to 1,401 calls but this increased to over 4392 calls in 1891.

Around the same time (1867) London, England started a service to convey smallpox victims to the hospital. London received 6 horse-drawn carriages which had been modified to accept specially designed litters to carry patients. These are the first dedicated ambulance stretchers. The users of this service had to pay a fee for the service.

Dedicated ambulance services began in London in 1887 as the St John Ambulance Brigade. This brigade is still in service today (see the order of St John).

The History of Ambulances in the early 20th Century
The late 19th century saw the invention of the automobile. These automobiles were gasoline powered, electric powered and even steam powered. The first motor powered (electric) ambulance saw service in Chicago, IL at the Michael Reese Hospital in 1899. It was purchases with donations from 500 prominent Chicago businessmen. In 1900 New York city acquired its first motor powered (electric) ambulance.

The first gasoline powered ambulance in the history of ambulances was the Palliser Ambulance introduced by Major Palliser of the Canadian Army. This ambulance was heavily armored and had a single steering wheel and tracks. It was designed for military use. The first mass-produced ambulance appear in 1909 and was manufactured by the James Cunningham, So and Company of Rochester, NY. This company was noted for building hearses and carriages. This ambulance had some notable features. It had electric lights which was unusual at the time. The cot used to transport patients had its own suspension and there were 2 seats for ambulance attendants. It had pneumatic tires, many tires of the time were solid. This provided better patient comfort in that is smoothed out the bumps. The ambulance had a 32 horsepower 4 cylinder internal combustion engine. It also had a side mounted gong to alert other carriages and pedestrians that an ambulance was coming through.

The History of Ambulances in the War Years (WW I and WW II)
World War I saw motorized ambulances replacing horse-drawn types.

In the civilian world, ambulances were being based out of hospitals and were being staffed by doctors. Some areas of the country used telegraph and telephones to call the police who would then dispatch the ambulance.

The equipment on board ambulances were also changing. Besides the standard splinting, traction splints were being used to immobilize femur fractures. This was borne out of evidence collected during World War I where these devices had a positive outcome on patient morbidity. Femurs were stabilized in the field rather than amputated.

Communications were improving. Many ambulances began to have two-way radios. This allowed for a more effective use of resources. Police dispatchers could now send ambulances to where they were needed the most.

The beginnings of air ambulances were beginning to take shape. In the outback in Australia, the distance between doctors and their patients were vast. Frequently a doctor (also a pilot) would fly to his patient to take of him and if need be, fly them back to a hospital.

During World War II, doctors were in short supply for the war effort. Many doctors were drafted into military service and pulled from the ambulances. Many funeral services picked up the pace since their vehicles could transport a patient in the supine position.

The History of Ambulances in the Post-War Period
Korea saw the use of helicopters to transport the wounded to Mobile Army Surgical Hospitals (MASH).

During the Korean conflict, over 18,000 wounded solders were transported via helicopter.

The history of ambulances began to change in 1952 after a horrific train wreck in Great Britain known as the Harrow and Wealdstone Rail Crash. This crashed kill 112 and injured 340 others. Many of the dead could have been saved if they had the proper equipment on scene. Ambulances were beginning to be restructured to become mobile hospitals rather than just a vehicle to transport patients.

New lifesaving techniques and equipment were also becoming available. Cardiopulmonary resuscitation (CPR) and defibrillation were becoming a standard out of hospital procedure for cardiac arrest. Oxygen delivery systems and the need to have more room in the back of the ambulance necessitated the need for bigger and better supplied ambulances.

The car chassis based ambulances that had been in use were too underpowered and too small to carry the new loads. New standards had to be developed to create safe ambulances.

The History of Ambulances in the Modern Age
In 1966 the National Academy of Sciences published its ground breaking paper "Accidental Death and Disability: The Neglected Disease of Modern Society "
This paper outlined what was currently wrong in the ambulance services at the time. It recommended changes in ambulance attendant training. The paper also outlined changes to ambulance construction. This resulted in the General Services Administration KKK ambulance specification.
The history of Ambulances will continue to evolve. What is commonplace now will be looked upon as archaic in the future.

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