Evolution of the Ambulance

Throughout history men devised methods to transport the ill and injured. Hammocks were readily available and used for centuries. During the time of the Romans and Greeks, chariots served as ambulances. In 900 A.D. attendants used a wagon with hammocks in it. While this was a step forward, these wagons lacked effective brakes. Imagine swinging back and forth or traveling downhill in one of these conveyances. In 1100 A.D. the Normans arrived in England with the innovative horse litter. These units consisted of two horses with special harnesses that suspended a bed between them.


The most common definition for ambulance is a vehicle that transports sick or wounded people. However, historians include Ferdinand and Isabella's contribution when describing the word ambulance. In the late 1400s they introduced ambulancias or field hospitals. This was the first time medical and surgical supplies were put in special tents to treat the wounded. But it took another three hundred years before troops wounded in battle were brought to the field hospitals and aid came to those who could not be moved.


Dominique Jean Larrey, a French surgeon, worked on the battlefields in the 1700s. He saw first-hand the need for care as soon as possible. Prior to this time army regulations required that the clumsy, heavy hospital wagons were stationed at the rear of the armies. Larrey developed lightweight, two-wheeled wagons. Not only did they take the wounded to the hospital but they also brought the surgeons to the battlefield. These became known as "flying ambulances" because they stayed with the "flying artillery" on the battlefield.


Pack animals often served as ambulances. Horses, mules and camels carried the injured for care. Attached to them were litters or chairs, also known as cacolets. These held one or two soldiers. Over time the apparatus grew more elaborate as men sought to create safer and smoother rides.


The Civil War showed the glaring need to improve care for the wounded. According to reports, none of casualties in the 1st Battle of Bull Run traveled by ambulance to Washington but some walked the twenty-seven miles for treatment. Those first assigned to remove the wounded were regimental musicians or soldiers who were not good fighters. These soldiers were placed on ambulance duty and served as medical assistants. During 1861, these men helped themselves to medicinal liquor or ignored the wounded to stay out of the line of fire. Surgeons treated only the soldiers who belonged to their regiment but the number of casualties became overwhelming.


Charles S. Tripler who served as Surgeon General of the Army of the Potomac Medical Department tried to improve the situation but when he was unsuccessful Dr. Jonathan Letterman was appointed to his position on July 4, 1862. Letterman graduated from medical school in 1849 and entered the military the same year. Until 1861 he served on the western and southwestern frontiers and was present during the wars with the Indians. The experience he gained treating and transporting the injured proved invaluable. Under Dr. Letterman's program, Medical Department officers selected soldiers who participated in the care and delivery of the wounded. Stretcher-bearers delivered the injured to primary centers. After rudimentary treatment ambulances carried the patients to field hospitals and then later moved them to the general hospitals by ambulances, rail cars or boats.


A train's facilities could range from a bed of straw or hay on the floor of a freight car to a passenger car made by the railroad manufacturers to deliver the wounded. Another possibility was a car with bunks or with litters attached to supports that had springs or rubber to absorb the movement of the car. Some trains served only as a large ambulance while others had cars with kitchens, storerooms, medical supplies and operating facilities. As with the trains water travel could range from a boat pressed into service to move the injured to steamboats outfitted as hospitals. Some could accommodate hundreds of men. Both the train and ship were new ways for the military to care for the wounded.


In 1864, Congress passed the Ambulance Corps Act. This was also called "An Act to Establish a Uniform System of Ambulances in the Armies of the United States." No longer were ambulances a part of the general transportation system. They now fell under the jurisdiction of the head of the medical department who was responsible for all aspects of the ambulance service: its administration, personnel and vehicles. To identify the ambulance corps special uniforms were designed and the ambulances were marked with distinct labels. This program became a model that was emulated throughout the world until World War I.


The Geneva Convention of 1864 was an international meeting called to reach an agreement for the treatment of the wounded and their caregivers on the battleground and at the hospitals. All of these individuals were granted neutrality. Included in the treaty were sanitary supplies, equipment and ambulances. A protective sign was adopted, now recognized worldwide as the Red Cross. (While the Red Cross Organization is international, each nation has its own independent societies, to serve the needs of that particular country.) Over the years the scope of the Geneva Conventions broadened to include the sick at sea, prisoners of war and protection of civilians.


Many hospitals that ministered to Civil War soldiers kept their ambulance service after the war. Records show that an Ohio hospital, Commercial Hospital (now known as Cincinnati General Hospital) had the first service for the general public in 1865. The ambulance driver's annual income was $360.


In New York, Dr. Edward B. Dalton, who had served as an army surgeon founded an ambulance service at Bellevue. Begun in 1869, it had 1401 calls in 1870 and by 1891 that number increased to 4392. While this increase is noteworthy five other hospitals in New York City also provided ambulance service by 1891. Bellevue's ambulances assigned doctors or surgeons to accompany them. The vehicles were well equipped with stretchers, handcuffs and strait jackets. Located under the driver's seat were a box with brandy, two tourniquets, six bandages, sponges, splint material and a small bottle of persulphate of iron. The lightweight carriage weighed between six hundred and eight hundred pounds and had a moveable floor that could be drawn out to receive the patient. Drivers earned an annual salary of $500 including room and board. Horses were stabled close to the hospital and like the fire service used special harnesses to attach the animals to the vehicle and get them on the street as soon as possible. Other public ambulance services connected to hospitals sprang up in Liverpool, Great Britain and in cities around the United States.


In 1899, the first motorized ambulance came on the scene. Made in Chicago and donated by five businessmen to Michael Reese Hospital; it weighed sixteen hundred pounds and traveled at sixteen miles an hour. In 1900, New York's St. Vincent Hospital obtained its first horseless vehicle. Katherine Barkley includes this quote from The New York Herald in The Ambulance: "An ambulance of this kind [motorized] possesses many advantages over its horse-drawn prototype. A greater speed is attainable; and there is more ease and safety for the patient; it may be stopped within its own length when running at full speed, and on account of its weight it runs with greater smoothness." The first motorized ambulances had two horsepower electrical engines and had the capability of traveling as far as twenty to thirty miles. The doctor in the back of the vehicle could communicate with the driver via a speaking tube. These came equipped with electric lights, both inside and outside, with a ten candlepower intensity. A well-known manufacturer of ambulances was Hess and Eisenhardt of Cincinnati, Ohio. They first began building ambulances in 1890 and produced a motor-driven ambulance in 1906. In 1937, they built the first air-conditioned ambulance in America. This company, now known as O'Gara-Hess and Eisenhardt, no longer makes ambulances but produces armored vehicles for passengers.


When World War I began some ambulances were still horse-driven. But as war continued buses were put into service and Parisian taxis were adapted to serve as ambulances. When the United States entered the war they brought Model-T Fords with them for many purposes. The framing on those used as ambulances was increased to provide adequate space for the litters. These vehicles could travel as fast as 45 miles an hour and served well on the rough terrain. The 1915 ambulances had painted canvas stretched across a frame but the following year light wooden slats were added to the frame and then canvas placed over it. One thousand vehicles were manufactured before America entered the war. As the war progressed the United States made more of these units and distributed the bodies to the British and French and they put their own identifying marks on the canvas. During the 1920's the ambulances were put to use on military airfields in the United States.


Transport by air for the wounded actually began before World War I. A Dutchman named DeMooy thought hot air balloons would prove useful. His idea was to suspend a giant stretcher under the balloon and have horses haul it. During the Great War the French Air Service is credited with the first use of an air ambulance when a Serbian officer was taken from the field to a hospital. "Records kept by the French at the time indicated that, if casualties could be evacuated by air within six hours of injury, the mortality rate among the wounded would fall from 60 per cent to less than 10 per cent -a staggering reduction!" (Air Ambulance). The British first used an air ambulance in 1917, reducing a trip that would have taken three days by land to a forty-five minute flight. While aircraft were used to take the injured for care if wasn't until the late1920s that the planes were specifically outfitted as ambulances. In 1928 the Australians ran an air ambulance service. It held a pilot, doctor, and nurse and had space for one stretcher patient. During its first year of operation it treated 225 patients traveling 200,000 miles. This organization is known as The Royal Flying Doctor Service of Australia and still exists today. The United States Air Corps designed three planes to perform as ambulances in 1929. These carried two patients on stretchers, a pilot and an attendant. The first reported case of the British using air ambulances for the general public was in 1933 when a patient on the verge of peritonitis was flown to a hospital.


During World War II various countries provided vehicles to use as ambulances. The United States converted a Dodge truck with a six-cylinder engine that had four forward speeds and weighed half a ton. The British used the Rover 9 on the front lines. It had space for two stretchers, or one stretcher and three seated wounded, or six seated wounded. Another British ambulance used by the Allied troops was the Bedford. The nineteen-foot long Bedford had a four stretcher capacity or could accommodate ten seated wounded. Another type of ambulance used during the war was the half-track configuration (these had wheels and tracks or were amphibious vehicles). The half-tracks were put to good use over rough terrain and along the beaches.


Helicopters first arrived on the scene in 1907 but Paul Cornu's model was not usable. The man credited for producing a successful helicopter is Igor Sikorsky, a Russian-born American. Sikorsky entered the United States to work in aviation but was unable to find employment. He first started working on helicopters in 1910 but it wasn't until 1939 that his craft flew successfully. Sikorsky is credited with the following quote: "If a man is in need of rescue, an airplane can come in and throw flowers on him, and that's just about all. But a direct lift aircraft could come in and save his life." (http://www.sikorskyarchives.com/indexlnk.html) Helicopters were used for medical evacuation during World War II. In 1944, a helicopter in New York carried blood plasma to a hospital in New Jersey that was treating victims of a steamship explosion. It wasn't long before both military and civilian agencies utilized helicopters for rescues and evacuations. Today helicopters continue to provide an invaluable service in the care and transport of critically ill patients to trauma centers throughout the world.


"Gradually, especially during and after World War II, hospitals and physicians faded from prehospital practice, yielding in urban areas to centrally coordinated programs. These were often controlled by the municipal hospital or fire department, whose use of "inhalators" was met with widespread public acceptance." (Annoted [sic] History and Biblbiography [sic] of EMS, link no longer active as of December 2007) Nationwide, the hearse often served as an ambulance. Or the local ambulance was a converted hearse, designed to deliver a patient as quickly as possible. The ambulances had space for the patient to lie down but lacked room for an attendant to ride in the back with them. Texas passed legislation in 1947 to regulate their ambulance operators. They were required to carry a traction splint, oxygen and minimal first aid equipment and their workers needed to have first aid training. The philosophy at this time was that emergency care began when the victim or injured person arrived at the hospital.


In the late 1950s and the 1960s, two key advancements:  mouth-to-mouth resuscitation and closed cardiac massage caused medical professionals to recognize the impact of having trained community members in the field who could respond quickly to medical emergencies. The physicians came to the realization that treatment at the scene, especially for heart attacks, could make the difference between life and death. At the same time, statistics recorded 50,000 fatalities from automobile accidents. The federal government saw an urgent need for changes in emergency care and transportation in communities and provided funding. Emergency Medical Services Programs began around the country. There are excellent resources that provide a history of these programs. (See the links at the end of this article.)


In 1965 The Accidental Death & Disability Paper stated that the style of ambulance in current use (station wagon or limousine chassis) was inadequate. More space was needed for the patient, attendant and equipment. Four years later a report titled "Medical Requirements for Ambulance Design and Equipment" was submitted to the Department of Transportation-National Highway Traffic Safety Administration. The 1973 EMS Systems Act, passed in 1974, required that communities receiving federal funds for their programs had ambulances that met new federal specifications. Three chassis styles meet the criteria and are still in use today: Type I uses a small truck body with a modular compartment, Type II has a van body with a raised roof and Type III has van chassis with a modular compartment.


As we enter the twenty-first century, experts continue to discuss changes for ambulances. With the possibility of bioterrorism and naturally occurring communicable diseases, the air quality in the ambulance is receiving attention. Air circulation and filtration need improvement to protect both the patient and those who render care. Occupant safety and equipment access are also items to be addressed. Emergency Service workers are beginning to voice their needs as new vehicles are purchased. They are influencing the design of the unit in such areas as vehicle visibility, sliding side-entry doors and the needs of specialized units (i.e. cardiac or neonatal).


Over the years Emergency Medical Services have saved countless lives with ambulances, aircraft, and boats by providing care at the scene and carrying the ill and injured for further treatment. What does the future hold as modes of transportation evolve and improve?



Maloney, Robert J. “The Evolution of Patient Transport.” FireEMS July/Aug. 2003: 52-60.

"Air ambulance."

"Ambulance." Dictionary.com Lexico Publishing Group.

Ambulance Corps "Transporting The Wounded."

"Annoted [sic} History and Bibliography [sic] of EMS by seen by USA Department of Transport."
(Link no longer active as of December 2007)

Barkley, Katherine Traver. The Ambulance: The Story of Emergency Transportation of Sick and Wounded Through the Centuries. New York: Kiamesha Lake, NY, 1978.

Bellis, Mary. "The Helicopter."  About.com.  2009. 

“Convention for the Amelioration of the Condition of the Wounded in Armies in the Field. Geneva, 22 August 1864.”  International Humanitarian Law-Treaties & Documents  International Humanitarian Law.  2005. 

"First Helicopter Civilian Rescue Nov. 29, 1945."

"Hear sirens today, you think saving lives; ambulances originally transported wounded."
(Link no longer active as of December 2007)

Knights, Edwin M., Jr. "Bellevue Hospital."

"Geneva Conventions."  (Link no longer active as of December 2007)

Ortiz, Jose M. The Revolutionary Flying Ambulance of Napoleon's Surgeon.

"Some on the Bare Ground, Some on Planks and Stretchers."

“Texas EMS History.”  Texas Department of State Health Services  27 February 2007.

"Transportation of Federal Sick and Wounded."

"Union Army Ambulance Corp."

"World War I Military Field Ambulance." U. S. Air Force Museum of Aerospace Medicine.   (Link no longer active as of December 2007)

Links for History of Paramedics and EMS:

"History of EMS Systems."  The Florida Department of Health 

"Los Angeles County Paramedic Program."

Page, James O.  The Paramedics.  Morristown, NJ:  Backdraft, 1979.

This article originally appeared online at Firefighters’ Real Stories.