AMBULANCE (from the Fr. ambulance, formerly hopital ambulant, derived from the Lat. ambulare, to move about), a term generally applied in England and America to the wagon or other vehicle in which the wounded in battle, or those who have sustained injuries in civil life, are conveyed to hospital. More strictly, in military parlance, the term imports a hospital establishment moving with an army in the field, to provide for the collection, treatment and care of the wounded on the battlefield, and of the sick, until they can be removed to hospitals of a more stationary character. In 1905-1906 the term "field ambulance" was adopted in the British service to denote this organization, the former division of the ambulance service into "bearer companies" and "field hospitals" being done away with. The description of the British service given below applies generally to the system in vogue in the army after the experience gained in the South African War of 1899-1902; but in recent years the medical arrangements in connexion with the British army hospitals have been altered in various details, and the
changes in progress showed no sign of absolute finality. Some of these, however, were rather of nomenclature than of substance, and hardly affect the principles as described below.
The ambulance organization which, variously modified in details, now prevails in all civilized armies, only dates from the last decade of the 18th century. Before that time wounded soldiers were either carried to the rear by comrades or left unattended to and exposed until the fighting was over. Surgical assistance did not reach the battlefield till the day after the engagement, or even later; and for many of the wounded it was then too late. In 1792 Baron Dominique Jean Larrey (1766-1842) of the French army introduced his system of ambulances volantes, or flying field hospitals, capable of moving with speed from place to place, like the "flying artillery" of that time. They were adapted both for giving the necessary primary surgical treatment and for removing the wounded quickly from the Sphere of fighting. Napoleon warmly supported Larrey in his efforts in this direction, and the system was soon brought to a high state of efficiency in the Grande Armee. About the same time another distinguished surgeon in the French army, Baron Pierre Francois Percy (1754-1825), organized a corps of brancardiers, or stretcher-bearers. These were soldiers trained and equipped for the duty of collecting the wounded while a battle was in progress, and carrying them to a place of safety, where their wounds and injuries could be attended to.
An important step towards the amelioration of the condition of the wounded of armies in the field was the European Convention signed at Geneva in 1864, by the terms of which, subject to certain regulations, not only the wounded themselves but also the official staff of ambulances and their equipment were rendered neutral, the former, therefore, not being liable to be retained as prisoners of war, nor the latter to be taken as prize of war. This convention has greatly favoured the development of ambulance establishments, but as all combatants have not the same knowledge of the conditions of this convention, or do not interpret them in the same way, charges of treachery and abuse of the Red Cross flag are but too common in modern warfare.
The American Civil War marked the beginning of the modern ambulance system. The main feature, however, of the hospital organization throughout that war was the railway hospital service, which provided for the rapid conveyance of the sick and wounded to the rear of the contending armies. Hospital carriages, equipped with medical stores and appliances, for the transport of cases from the front to the base, were rapidly introduced into other armies, and played a great part in the ambulance service of the Franco-German War.
The German hospital service as existing at the time of the Franco-German War of 1870-71 was modified and extended by the Kriegs Sanitats Ordnung of 1878 and the KriegsEtappen Ordnung of 1887, which completed the organization by the addition in time of war of numerous subordinate offices and departments. The main divisions of the ambulance organization of the German army in the field fall into: (1) sanitary detachments, (2) field hospitals, (3) flying hospitals, (4) hospital reserve depots, (5) "committees for the transport of the sick," and (6) railway hospital trains. The whole administration of the ambulance service of the grand army in the field is in the hands of the chief of the ambulance sanitary staff, who is attached to headquarters. Next in command come surgeons- general of armies in the field, surgeons-general of army corps, and under them again surgeons-in-chief of divisions and regiments. Civil consulting surgeons of eminence, and professors from the universities, are also attached to the various armies and divisions to co-operate with and act as advisers to the surgeons of the standing military surgical staff. The hospital transport service on the lines of communication is highly organized and the hospital railway carriages are elaborately equipped.
French system. The French ambulance system, finally settled by the reglement of 1884, is organized on almost identical lines with the German; one of the principal peculiarities of the former being the ambulances volantes already referred to. The peace organization of the German and French systems does not materially differ from that of the British service.
In the Japanese army a special feature is the sanitary corps, whose duty is the prevention of disease among the troops; it has been brought to a great pitch of perfection, with the result that in the Russo-Japanese War (1904-1905) the immunity of the troops from all forms of preventable disease surpassed all previous experience. Not only was the army accompanied by sanitary experts who advised on all questions of camping grounds, water supply, etc., but before the war began the Intelligence Department collected information as to the diseases of the country likely to be the scene of operations, unhealthy places to be avoided, and precautions to be taken.
British army system.
Coming now to the ambulance system of the British army, in which are comprised the arrangements and organization of the medical department for the care and treatment of the sick and wounded from the time they are injured or taken ill, till they are able to return to duty or are invalided home, we will trace the progress of a wounded man from the field of battle to his home; remembering that, as British troops are usually engaged overseas, hospital ships as well as land transport are necessary.
First field dressing.
When a soldier falls wounded in action he is attended by the regimental surgeon and stretcher-bearers, who apply some extemporized method of stopping bleeding and dress the wounds with the "first field dressing" - a packet of antiseptic material which every officer and man on active service carries stitched to some part of his clothing, and which contains everything necessary for dressing an ordinary gunshot wound. Recent wars have demonstrated that in all uncomplicated cases it is better to leave this dressing undisturbed, as the wounds made by modern projectiles heal up at once if left alone, if air and dirt have been thus excluded.
From the field he is carried on a stretcher by bearers (formerly of the "Bearer Companies") of the Royal Army Medical Corps to the collecting station, where he is placed on an ambulance wagon of the first line of assistance and taken to the dressing station. Here his would will be examined if considered necessary, but as on the field the first medical officer who examined him has already attached a "specification tally" to the patient, giving particulars of the wound, it will probably not be disturbed unless complicated by bleeding, splintering of bone or some other condition requiring interference. Any operation, however, which is urgently called for will be here performed, nourishment, stimulants and opiates administered if required, and the patient moved to the field hospital in an ambulance wagon of the second line of assistance. From the field hospital he is transferred as soon as possible by the ambulance train to the general hospital at the advanced base of operations, and from there in due time in another train to the base of operations at the coast, from which he is ultimately either returned to duty or sent home in a hospital ship. The organization by which these requirements are fulfilled is the following: -
Every regiment and fighting unit has posted to it, on proceeding on active service, a medical officer who looks after the health of the men and advises the commanding officer on sanitary matters. When the regiment goes into action he takes command of the regimental stretcher-bearers who, to the number of two per company have been in peace time instructed in first aid and in the carrying the wounded on stretchers. These men leave their arms behind and wear the Red Cross armlets, to indicate their non-combatant functions, but in these days, when a battle is often fought at long ranges, it is not to be wondered at, or attributed to disregard of the red cross flag by the enemy, if medical officers and stretcher-bearers are hit. The bearer company into whose charge the wounded man next passes is composed of men of the Royal Army Medical Corps, with a detachment of the Army Service Corps for transport duties. In future, bearer sections of the Field Ambulances will perform the duties of the bearer company. Its function is to collect and succour the wounded on the battlefield and to hand them over to the field hospitals, with which these bearer companies
are closely associated, though separately organized. In the Indian army the bearer company is provided from the personnel of the field hospital when there is a battle, and reverts to the hospital again after it is over. The war in South Africa of 1899- 1902 clearly demonstrated the superiority of the Indian plan; for after the action the bearer company staff should be available to give the much-needed help in the field hospital, and some amalgamation of the two organizations, or something after the plan of the ambulance volante of the French, is necessary. The bearers afford the wounded any treatment required, supply water and sedatives, and then carry them back on stretchers to the collecting station in the rear, whence they are conveyed to the dressing station in the wagons or other form of transport.
At the dressing station, which ought to be out of range of the firing, and should have a good water supply, the patient is made as comfortable as possible, nourishment and stimulants are administered, and he is then taken to the field hospital. In times of great stress, when it is desirable to remove the wounded quickly from the field, and there are no roads or wheeled transport is not available, large numbers of bearers are employed to carry them on stretchers, etc. These men are engaged locally and are soon given the slight training necessary. This was done in Natal after the battles on the Tugela (1899), in which there were some thousands of wounded to be conveyed; also in Egypt, where the local troops not required for the fighting line were requisitioned; the Japanese in Mongolia employed hundreds of Chinese coolies for this purpose, the general use of sedan-chairs in China having accustomed the poorer class of natives to this kind of labour.
In India, the rank and file of the Royal Army Medical Corps not being employed, the bearer work is carried out by natives specially enlisted and organized into a corps. These men are bearers by caste - a reminiscence of the system which prevailed generally a hundred years ago, and is still met with in out-of-the-way places, of conveyance of travellers in dhoolies, which are closed wooden carriages fixed on long poles and carried on men's shoulders. The bearers convey the wounded in dandies, similar to dhoolies, but made mostly of canvas, so that they are much lighter. The courage of these bearers on the battlefield has often been praised. The old bearer caste is, however, rapidly dying out owing to the general discontinuance of the use of dhoolies. Thus the ambulance organization in India is entirely different from that in other parts of the British empire. The rank and file of the Royal Army Medical Corps are not employed there, although the medical officers are. The warrant and non-commissioned ranks are replaced by a most useful body of men of Anglo-Indian or Eurasian (half caste) birth, called the Subordinate Medical Department, the members of which, now called assistant surgeons (formerly apothecaries), receive a three years' training in medical work at the Indian medical schools and are competent to perform the compounding of medicines and to deal with all but the most serious cases of injury and illness. In the hospitals the men of the Royal Army Medical Corps are replaced by the Native Army Hospital Corps, subdivided into ward-servants, cooks, water- carriers, sweepers and washermen. The caste system necessitates this division of labour, and the men are not so efficient or trustworthy as the white soldiers whose places they take. The bearers of the wounded are a separate and distinct class, partly attached to regiments, etc., as part of the regimental transport, and partly organized into bearer companies, attached to field hospitals. The dandies in which they carry the wounded are much more comfortable than stretchers, being fitted with roofs and sides of canvas to keep off Sun and rain, thus being collapsible so that the dandy is quite flat when not in use. Still they are heavy, clumsy, and cannot be folded up into a small compass for transport like a stretcher; they also take up a good deal of room in wagons and can scarcely be carried on the backs of animals owing to the length of the pole. Hence riding ponies and mules are much used in Indian warfare, especially in the mountains, for the carriage of less seriously wounded men. In India separate hospitals are necessary for white and native troops, and the latter have accommodation for the large numbers of non-combatant camp-followers, mule-drivers, cooks, officers' servants, etc., etc., which constitute one of the most remarkable features of the Indian army organization.
Field hospitals, under the new scheme furnished by tent sections of the Field Ambulances, are each supposed to provide accommodation for 100 patients, who live on their field rations suitably cooked and supplemented by various medical comforts. The patients are not supplied with hospital clothing, nor do they have beds, but he on straw, which is spread on the ground and covered with waterproof sheets and blankets; of these latter a considerable reserve is carried. These hospitals can and must at times accommodate more than the regulation number of patients, but in the South African War their resources were at times considerably overtaxed, with consequent discomfort and hardship to the patients, the medical equipment proving insufficient for unexpectedly heavy calls upon its resources.
Hospitals on the lines of communication.
These hospitals are supposed to move with the army, and therefore it is imperative to pass the wounded quickly back from these to the stationary hospitals on the lines of communication (which vary according to the length of these lines) and thence to the general hospitals at the base. The size of the lines of communication hospitals varies according to circumstances, and they are as a rule "dieted," that is to say proper hospital diets and not field rations are issued to the patients, who also are supplied with beds and proper hospital clothing. In these hospitals also there may be nursing sisters, who of course are unsuited for the rough work and life nearer the front. Sisters are also employed on the hospital trains, which were found most useful and brought to great perfection in the South African War, being fitted with beds, kitchens, dispensaries, etc., so that patients were moved long distances in comfort.
Arrived at the base of operations the wounded are admitted to the general hospitals, of which the numbers and situation vary with circumstances, but each is supposed to have an officers' ward. In the South African War, owing to the inability of the comparatively small Royal Army Medical Corps to meet all the requirements of the enormous force which was ultimately employed, many of the doctors were drawn from the civil profession, and the rank and file from the St John's Ambulance Association and the Volunteer Medical Staff Corps, while many nursing sisters belonged to the Army Nursing Reserve, ordinarily employed in civil hospitals but liable to be drafted out during war.
Civil general hospitals.
In the South African War the patriotism and liberality of the British public furnished several large general hospitals, perfectly equipped, and officered by some of the most eminent members of the medical profession in the United Kingdom. Among others may be mentioned the Princess Christian, the Imperial Yeomanry (both field and general hospitals), the Langman, the Portland, the Scottish, Irish and Welsh hospitals. These were staffed entirely by civilians, except that an officer of the Royal Army Medical Corps was attached to each as administrator and organizer; and their personnel was made up of physicians, surgeons, nurses, dressers (medical students and in some cases fully qualified surgeons) and servants; the numbers, of course, varying with the size of the hospitals. In addition to the staff of these hospitals several eminent civil surgeons, including Sir William Maccormac and Sir F. Treves, went out to the seat of war as consultants: an innovation in the British service, but in accordance with the system long in vogue in Germany.
To the Army Medical organization is affiliated in war time that of the Red Cross Society and other charitable associations, which during the South African War aided the Army Medical Service greatly by gifts of clothing, money and numerous luxuries for the sick and wounded.
Lastly, the wounded man is transferred to a hospital ship, which is fitted up with comfortable swinging cots in airy wards, with refrigerators for preserving provisions and the supply of ice, punkahs for hot weather, etc. Each division of an army corps is supposed to have one such ship, with from 200 to 250 beds and the same staff of doctors, nurses, etc., as a hospital of similar size on shore, when necessary.
Red Cross societies.
Different regulations are made by various powers as to the work of the Red Cross societies under the Geneva flag. Whereas in Germany and France such aid is officially recognized and placed under direct military control, the English Red Cross societies have acted side by side with, but independently of, the military ambulance organization. In the South African War (1899-1902), however, the bonds of union were drawn considerably closer, and cordial co-operation was brought about to prevent overlapping and waste of money. In Germany the volunteer organization is presided over by an imperial commission or inspector-general appointed in peace time, who in time of war is attached to the headquarters staff. His functions are to control the relations of the various Red Cross societies and secure harmonious co-operation. Delegates appointed by him are attached to the various corps and transport commissions. No volunteer assistance can be utilized which is not entirely subordinate to the military control, and has not already in peace time received official recognition and been organized on a skeleton footing. Moreover, only persons of German nationality can be employed under it with the armies in the field. In case of base hospitals situated in Germany itself, the services of foreigners may be employed when specially authorized by the war office. In France, in the main, the same rules obtain in the case of volunteer hospital service.
St. John's Ambulance Association.
Great attention has been paid to civil ambulance organization in England. In 1878 the British ambulance association of St John of Jerusalem was founded. Its object was to render first aid to persons injured in accidents on the road, railway, or in any of the occupations of civil life. As the result of the initiative taken by this society, ambulance corps have been formed in most large towns of the United Kingdom; and police, railway servants and workmen have been instructed how to render first aid pending the arrival of a doctor. This samaritan work has been further developed and extended to most parts of the British empire, notably Canada, Australia and India, and there is no doubt that many lives are saved annually by the knowledge, diffused by this association, as to how to stop bleeding, resuscitate the apparently drowned, etc. Moreover, during the South African War this association provided a most valuable reserve for the Royal Army Medical Corps, and drafted out some hundreds of partially trained men whose assistance was most valuable to the Army Medical Service in dealing with the enormous numbers of sick and wounded who came upon their hands.
Civil ambulance in America.
In America each city has its own system and organization of civil ambulance service. In some, as in Boston, the service is worked by the police; in others, notably New York, by the hospitals, while Chicago has an admirable service under municipal control. In most of the capitals of Europe similar systems prevail.
British ambulance wagons are built very strongly to stand rough roads, and are of several patterns; those used in the war in South Africa were reported on as heavy, uncomfortable, and so unwieldy as to be incapable very often of keeping up with the troops; but a new and more mobile vehicle, to convey four patients lying down as well as six seated, or fourteen all seated (whereas the old pattern wagons only accommodated two lying-down cases), has been introduced. All patterns of wagons weigh from 17 1/2 to 18 1/3 cwt., while the Boers and the British Colonial auxiliaries used much lighter-carts, which were taken at a gallop over almost any country. The Indian ambulances are small two-wheeled carts, called tongas, drawn by two bullocks or mules; very strongly made, they are capable of holding two men lying down, or four sitting up, besides the native driver.
Various other forms of transport are found, such as mule litters in mountainous districts, where wheeled carriages cannot go, camel litters in the Sudan, dhoolies in India, hammocks on the west coast of Africa, or sedan-chairs in China. In the Russo-Japanese War an ingenious form of mule litter for serious cases was made by fixing the ends of two long springy poles about 15 ft. long into each side of the pack saddles of two mules, one in front of the other, so as to support a bed for the patient between them; the length and resiliency of the poles prevented jolting of the wounded man, and the mules were able to carry him long distances over any kind of ground. The ordinary mule or camel litter provides for a wounded man (lying down) being carried on a sort of stretcher on either side of the animal, or in cacolets in which the less serious cases are slung in seats (one on each side of the animal), sitting up.
In Great Britain, the material and equipment required are stored in times of peace at the various headquarters stations and carefully examined twice a year; and on orders for mobilization being issued, the doctors and various ranks of attendants, who have previously been told off to each unit, repair to the allotted station, draw the equipment and transport, and embark with the brigade to which they are attached. The tendency of the present day is towards reduction in bulk and concentration of strength of drugs, points which simplify the question of transport of ambulance material. As the fighting man can carry concentrated nourishment enough for thirty-six hours, in the form of an emergency ration, in a tin the size of an ordinary cigar-case, and enough sweetening material in the form of saccharine to last a fortnight in a bottle smaller than an ordinary watch, so the medical department can take their drugs in the form of compressed tabloids, each the correct dose, and each occupying about one-tenth of the space the drug ordinarily would; while the medical officers can carry hypodermic cases, not so large as an ordinary cigarette-case, containing a syringe and hundreds of doses of highly concentrated remedies. Again, the traction engines which now accompany an army can also supply electricity for X-ray work, electric-lighting, ice-making, etc. (J. R. D.)
Note - this article incorporates content from Encyclopaedia Britannica, Eleventh Edition, (1910-1911)