AMBULANCE, the French ambulance, hôpital ambulant, derived from the Latin ambulare, to move from place to place.
Ambulances, in military phraseology, are hospital establishment moving with armies in the field and organized for providing early surgical assistance to the wounded after battles. They are only prepared for affording help of a more or less temporary kind, and they are thus distinguished from the stationary or fixed hospitals, in which sick and wounded soldiers receive care and treatment of a permanent character. The term is not un-frequently misapplied in common speech in England to the ambulance wagons, or other conveyances by which the wounded are carried from the field to the ambulances and fixes hospitals. Such vehicles form part of the ambulance equipment, and will be noticed presently.
The constitution of an ambulance includes (1) a certain staff of officers and subordinates, and (2) a certain equipment. The equipment naturally divided itself into (a) the medical and surgical equipment, and (b) the equipment forming the means of transport for the wounded. But the construction would hardly be understood without a general comprehension of the system on which the functions of ambulances are discharged, or, in other words, the plan of administering surgical assistance in the field to the wounded of armies. Ambulance administration will therefore be first noticed, keeping in view the circumstances of armies operating in Europe, and the ambulance staff and equipment subsequently.
AMBULANCE ADMINISTRATION --- the origin of the ambulance system which now prevails in all civilized armies, though variously modified among them in particular details, only dated from the last decade of the last century. Before that time no ambulance establishments has been organized for effecting the removal of the wounded, or for giving the requisite surgical attention to them, while battles were in progress. Soldiers wounded in the ranks were either carried to the rear by comrades, or were left to lie exposed to all risks, and unheeded, until after the fighting has ceased. The means of surgical assistance did not reach the battle-field till the day after the engagement, or often later, and to a large proportion of the wounded it was then of no avail. In 1972 Larrey introduced his system of ambulances volantes, or flying field hospitals, establishments capable of moving from time, They were adapted both for giving the necessary primary surgical help, and also for removing the wounded quickly out of the sphere of fighting. The first Napoleon warmly supported Larrey in his endeavors to introduce and perfect the new system of surgical aid to the wounded in battles; and , being received with much favour by the troops, the plan obtained a firm footing, and was subsequently brought to a high state of perfection. About the same time another distinguished surgeon of high position in The French army, Baron Percy, introduced and developed a corps of brancardiers, or stretcher-bearers. These consisted of soldiers trained and regularly equipped for the duty of collecting the wounded while a battle was in progress, and carrying them on stretchers to places where means of surgical aid were provided.
From the period when these improvements were introduced most civilized armies have had ambulance establishing formed for giving surgical help near to the combatants. It is only, however, during the last twenty years that ambulance have acquired the completeness of organization which they have now attained in some armies especially in those Germany. In the armies of the United States of America, during the late great civil war, the ambulance system attained a very complete organization, particularly from March 1864, when an Act was passed by Congress and single system of ambulance arrangements for all the armies of the United States at the time in the filed.
The ambulance arrangements of the British army have never reached the degree of completeness which they have reached in Continental armies. During the Peninsular war the want of a trained ambulance corps and of property-constructed sick-transport carriages, formed a theme of constant complaint. For the former, soldiers from the ranks were substituted --- a double evil, as they were unsuited for the work while their employment lessened the fighting strength; for the latter, commissariat wagons, or the agricultural carts of the country in which the troops were operating. It was not from want of attention being called to the subject, as the writing of Sir J. M Grigor, Hennen, Millingen, and other Peninsular surgeons sufficiently testify. The last-named military surgeon published a very complete scheme of an ambulance establishment shortly after the war concluded, approaching closely in its principal to those put into practice of late years in the armies of Germany. There is reason for believing that had the operations of the British troops on the Continent not been discontinued, some plan for the kind would have been introduced. As it was, subsequently to 1815, so far as army hospitals were concerned, administrative attention was chiefly given to improving those for the accommodation of the sick in peace time. The wars that British troops were engaged in India, China, the south of Africa, and elsewhere, did not lead to improvements like those which have been made in Continental armies; for either the habits of the natives of the respective countries, of the nature of the climate, or the state of the country, necessitated special arrangements for the care of the sick and wounded unsuited for meeting the circumstances of European warfare. Thus, when the Crimean war was broke out the English army was still without an ambulance corps, or an ambulance establishment of materiel. An ambulance corps of military pensioners was hastily raised, but failed from the habits and enfeebled constitutions of the men. They were succeeded by a corps formed of civilians, unused to the discipline and habits of military life, which likewise failed. Several forms of sick-transport vehicles were tried, but only indifferently answered their intended purposes. Fortunately, as the troops were for the most part stationary during the war, the want of thoroughly organized ambulances was not felt to the same extent as it would have been had the operations been extended far into the interior of the country. The experience of the Crimean war led to efforts to repair the defects which were then made manifest. Since that time a trained army hospital crops has been constituted, and much of the ambulance equipment has been revised.
One serious impediment to perfecting and ambulance system is the costliness of maintaining, in time of peace establishments which will only be required for use in time of war. All that can be done is to form a nucleus which can be expanded according to need when war breaks out. Bet even in Continental armies, with frequent wars pressing upon them, the urgency of giving close attention to the subject and in countries where the existence of conscription furnishes a greater supply of men at less cost than in England, the deficiencies of the ambulance establishments have hitherto been so great in respect to the numbers and necessities of the wounded on occasions of great battles, that an extensive volunteer organization, with national societies in every country of Europe, has sprung up for giving additional assistance. This is not the place to discuss the advantages of such volunteer aid; but, if accepted, all who have considered the subject will have admitted the necessity for its being placed under military authority, and under distinct regulations in order to secure maintenance of order and disciple. It is also generally admitted that volunteer aid to wounded soldiers is out of place in the ambulances, and can best employed in the fixed hospitals, by which be set for word in the field.
One important step, taken a few years since, towards the amelioration of the condition of the wounded of armies in the field must be just mentioned. This was the European Convention signed at Geneva in 1864, by the terms of which, subject to certain relations, not only the wounded themselves, but the official staff of ambulances and their equipment have been 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 favored the development of ambulance establishment.
The conditions of modern warfare have not led to the need of army ambulances being arranged on principles different from what were applicable only a few years ago. The immensely increased range of rifles and artillery in the present day, the consequent extension of the are over which fire is maintained, the suddenness with which armies can be brought into the field from increased facilities of locomotions, the rapidity of their movements, the shortened duration of campaigns, the large numbers of wounded which have to be dealt with , not merely from the destructive qualities of the fire-arms, but from the destructive qualities of the fire arms, but from the vast forces collected on occasions of important battles, the increased which have entailed need for revision of ambulances and their administration. The ambulances must be so organized as to be able to keep up with the troops and so disposed as in no way to interfere with their movements. They must be capable of meeting the wants of a partial or general engagement at any moment, and if the troops advance, must be prepared to accompany them, so as to be ready to meet future wants.
Whatever the details of organization may be when an importance battle is fought, the ambulance system must admit of three help stations at least being established in rear of the combatants. There must be a station of limited character immediately in rear of the troops for attention to such wounds as entail speedy loss of life if no assistance be rendered; a second station, more remote, where temporary assistance of a more general nature can be afforded; a third, where more thorough attention can be given, and where the wounded can receive food and protection until there are means of sending them away. Recently, in some armies, the ambulance arrangements have been calculated for furnishing aid at four stations; and, indeed, owing to the increased range of fire, and the consequent distance between the help stations when only three formed , the fatigue thrown on the bearers is so great, and the time the wounded are left without help so long, that the division of the ambulances into four stations has become almost essential. If this arrangement be followed, there will be --- 1st, the field station, for help of prime urgency; 2nd, the transfer station, where the wounded will be transferred from the hand conveyances to wheeled vehicles; 3rd, the dressing station, where the provisional dressing will be applied; and 4th, the field hospital station, where definitive treatment will be adopted.
The disposition and distances of these four ambulance sections must vary according to the nature of the battle, the configuration of the terrain, and other circumstances, but in a general way will be as follows: --- 1st, the filed station, in the immediate rear of the troops, moving with them, and therefore under fire; 2d, the transfer station, clear of the enemys rifle fire, but not to far for the bearers, and at the place practicable for wagons, from 800 to 900 yards behind the troops engaged; 3d, the dressing station, beyond range of the artillery fire, at a spot easily reached by the ambulance wagons, and on the way to the fourth station, with a running stream or well at hand if possible, from 800 to 1000 yards in rear of No. 2; and 4th, the field hospital station, at a place free from risk of being brought bithin the sphere of fighting, from 2 to 4 miles in rear of the combatants. This last station may be at a farm or country house, or in a village, but should not be in a place of strategical importance, or in one likely to be blocked by the general transport of the army. When the four stations are in working order, as men fall badly wounded, those within reach will be placed on stretchers by the men told off for duty as bearers, and, after hasty inspection by the field surgeon, and as far as practicable, receiving such help as is of vital importance, they will be borne to the second or transfer station, and placed in ambulance wagons, or on wheeled stretchers if they are in use. The bearers, then taking vacant stretchers, will return to the field station for more wounded. The wounded who have been transferred to the wheeled conveyance will be driven by the men of the ambulance train to the third or dressing may be necessary before being sent on to the fourth or field hospital station, where definitive treatment will be adopted, and any surgical operations performed that may be required.
It is obvious that such system of help can only be carried out, with any approach to regularity and requisite speed, with ambulance establishments proportionate to the number of troops in the field, each ambulance being well organized, provided with a sufficient staff and complete equipment, and acting under the general supervision of an experienced director, whose duty is to watch the varying events of the contest while it is in progress, and to order changes in the ambulance arrangements according as the troops advance, retire, or otherwise change position. Even with these advantages, the difficulties of adequately meeting the wants of the wounded must always be very great, owing to the rapid maneuvers of the troops, the varying features of the ground over which battles are extended, and the rapidity with which the wounded fall; but without a proper organization arranged beforehand, the difficulties are insuperable, and no help of much value can be afforded until all fighting has ceased.
Ambulance arrangements have to be modified to suit particular military operations, such as when troops disembark on a hostile shore, on occasion of sieges, &c.
AMBULANCE STAFF. --- The scheme of ambulance administration and action just described involves the necessity of a staff comprising the following personnel, viz. :--- 1.Bearers of wound; 2. Surgeons and attendants; 3. Ambulance train personnel; 4. Ambulance police; 5. servants of officers.
Bearers of Wounded. --- These are soldiers specially trained and told off for the duty of picking up and carrying the badly wounded on stretchers. In continental armies special provision is made to meet this particular want, but under different systems in different armies. In the Prussian army companies of bearers, distinguished by a particular uniform, and denominated "sanitats-detachements," have the duty assigned to them of gathering the wounded during the battles, and carrying them to the dressing and field hospital stations. Each of these bearer columns consists of a military staff of officers for discipline and direction, non-commissioned officers, buglers, and a large number of bearers; a special medical staff, with assistants and dressers; a transport staff of non-commissioned officers and drivers, with a certain number of stretchers, wheeled stretcher supports, sick transport wagons, and store wagons for the carriage of instruments, dressings, and other necessary materials. Separate establishments exit for the field hospitals. In addition to these sanitary detachments, auxiliary sick-bearers (Hilfs-krankentrager) are provided for the service on occasions of great battles. To form these auxiliaries, four men in each company of every battalion of the army are practiced at a regular periods with the sanitary detachments in time of peace in the modes of picking up, temporarily attending to, and carrying wounded. These auxiliary bearers wear uniform of their regiments, of which they perform the ordinary duties, but have a distinguishing badge on the left arm when serving as bearers. When a battle is imminent, the auxiliary bearer fall out, are provided with stretchers and other needful appliances from the ambulance wagons, and act under the orders of the officers of the divisional sanitary detachments. The system in the Austrian army is very like that in the Prussian. In the British army no corresponding establishment exists. The hospital attendants belonging to the Army Hospital Corps are trained in all that refers to the care of wounded men, but in time of war they will be too urgently needed for their duties in the field and fixed hospitals to be spared for duty as bearers of the wounded from the field to the dressing stations. The regimental bandsmen are generally regarded as available for these duties in the British service; but though the army regulations order that bandsmen are liable to serve in the ranks on an emergency, they nowhere constitute them bearers of wounded, nor do bandsmen receive the necessary training to fit them for the duties. As it is understood that the ambulance arrangements of the British army are at present under consideration, this, with other details, will probably be shortly placed on a settled basis.
Surgical Staff. --- This section embraces the medical officers (administrative and executive), the dispensers of medicine, and the officers, non-commissioned officers, and men of the Army Hospital Corps. The last-named corps includes the dressers, nurses, cooks, and all the hospital subordinates who are required for the care, dieting, watching, and protection of the patients, for the hospital correspondence, &c. The men act professionally under the directions of the surgeons; in respect of other matters, under their own officers. The constitution and duties of the several divisions and grades of the army medical department are shown in a special code of instructions known as the "Army Medical Regulations."
Ambulance Train. --- On the officers and men of the ambulance train devolve the duties of conducting the wheeled transport, and the mule litters and cacolets when such conveyance are used. In the British service these duties are entrusted to the ordinary transport branch of the Control department. It has been recommended that the officers and men to whom these duties are entrusted should be specially selected and trained, as well as familiarized, to co-operate with the bearers and ambulance corps. They would thus form an ambulance train somewhat like that which exists in the sanitary detachments of the Prussian army.
Military Servants. --- Orderlies are required as servants to the ambulance surgeons and other officers in order that they may give their time fully to the concerns of the sick and wounded. When special orderlies are not provided, men of the Army Hospital Corps usually act as servants to officers, --- a bad system, for the whole time and services of these trained men should be devoted to their legitimate functions.
Ambulance Police. --- Many irregularities are liable to occur in the rear of troops engaged in a general action; not so much from acts of the troops themselves as from camp followers, hired drivers, and others. The officers charged with the military discipline of the bearer, train, and hospital corps has other pressing duties to engage them on such occasions. In the British army it devolves on the provost-marshal to arrange for this service.
AMBULANCE EQUIPMENT. --- As before mentioned, ambulance equipment divides itself into two categories : --- 1. The medical and surgical equipment; 2. The equipment for the transport of wounded. These divisions will therefore be noticed separately, and the description will be confined to the equipment supplied in the British army for service in Europe. In India and i9n tropical countries special ambulance equipments are rendered necessary.
Medical and Surgical Equipment. --- This portion of ambulance equipment consists of the articles necessary for the service of the wounded in the field itself, at the dressing stations, and in the field hospitals. It has to be distributed in forms such that it may be readily conveyed to the places where it is required, and such also as will admit of its being hastily packed up and removed should the circumstances of the field operations require it. At the same time, these forms must be adapted for use at all seasons of the year, for passage over all descriptions of ground that troops can march over, and must be protected against the effects of exposure to all varieties of weather.
It would occupy too much space to name the articles comprising this equipment. The special forms under which it is issued will be mentioned, and a brief explanation of them and the nature of their contents be added.
The equipment is distributed as follows: --- Supplies of instruments, dressings, medicines, and restoratives, of first necessity, in small cases named "medical field companions," and in large cases named "Field panniers;" of cooking utensils and other articles for field hospital service in "canteens;" of articles of light nourishment, stimulants, &c., in "medical comfort boxes;" of the hospital tents, bedding, and the bulkier articles of surgical equipment, in ambulance equipment carts or store wagons. In addition, every soldier on taking the field is supplied with a "field dressing;" each surgeon carries a pouch-belt, arranged both for distinguishing his functions and at the same time carrying his "pocket case" of instruments; and each Army Hospital Corps man has his "orderlys dressing-case." Every wounded man has therefore on his person the means of a first dressing for his wound, every surgeon has at hand instruments for affording surgical aid, and every ambulance and field hospital attendant the means of assisting the surgeon in his duties. Moreover, wherever the soldier can go, there the first two forms of the surgical equipment --- the medical field companion and the field panniers --- can also be taken. The articles for use in the field hospitals, being carried in wheeled vehicles, can only move where the other transport of the army can be taken.
Medical Field Companions. --- These are small cases carried by men of the Army Hospital Corps selected to accompany surgeons. They consist of two pouches and a wallet, worn nearly in the same way as the pouches and belt-bag in which ammunition is carried by combatant troops. The two pouches, carried on the waist-belt, contain small supplies of essential medicines and styptics; the surgical wallet, also carried on the waist-belt, and supported by valise straps, contains materials for surgical dressings and other articles. As these attendants are not armed with rifles, they can carry their valises and the medical field companions at the same time without inconvenience. With each medical field companion is carried, by a shoulder-strap, a water-bottle and a drinking-cup.
Field Panniers. --- These are tough wicker baskets covered with hide, each being 2 feet 2 inches in length, by 1 foot 2_ inches in breadth, and 1 foot 4_ inches in depth. They are supplied in pairs, and are arranged for being attached to a pack-saddle and carried on a bat-pony or mule. They are capable of being opened while on the animal in such a way that all the contents can be readily got at. The field panniers contain instruments for important surgical operations, chloroform, surgical materials (such as splints, bandages, and plasters, &c.), a lamp, supplies of wax candles, restoratives, and medical comforts in concentrated forms, and other articles necessary for urgent cases at the dressing stations and field hospitals. Each pannier has a double lid, and the four lids of the two panniers, when they are laid on the ground, can be connected so as to form a substitute for an operating table.
Field Hospital Canteens. --- These are also supplied in pairs, and are distinguished as A and B canteens. They are wooden boxes nearly similar in size to the field panniers, so that, although usually carried in the equipment vehicles, they can, in case of need, be carried on the backs of bat-animals. Their contents consist of camp-kettles and other utensils for cooking purposes; tin plates, drinking-cups, and other such requisites; sets of measures and weights; a lantern of colored glass for indicating the field hospital at night; together with various articles required for the services of patients in a tent or other field hospital.
Medical Comfort Boxes. --- These also are supplied in pairs, and resemble the canteens in shape and dimensions. The contents of the two are different, and they are therefore marked No. 1 and No. 2 respectively. Each box is partitioned and fitted with cases or bottles with labels indicating their contents. These principally consist of essence of beef, groceries, arrowroot, preserved vegetables, brandy, wine, and sundry accessory articles. The wounded are supplied with the same rations as the healthy troops, and they are turned to the best account available for their nutriment, supplemented by such medical comforts as are named above.
Ambulance Equipment Waggons. --- In these vehicles are carried the tents for forming the field hospital in case of no building being available, with a supply of blankets, waterproof covers, and other articles of bedding for the patients. The canteens and medical comfort boxes are also carried in these vehicles. Certain implements, as reaping-hooks, spades, pickaxes, saws, which are constantly required when men are thrown so much on their own resources as they must be in campaigning, are also carried in the equipment wagons.
Ambulance Equipment for the Transport of Wounded Troops. --- The ambulance conveyances authorized for use in the British army are of four kinds. They are the following: --- 1. Conveyances carried by the hands of bearers, called stretchers; 2. Conveyances wheeled by men, wheeled stretchers; 3. Conveyance borne by mules, mule litters and mule cacolets; and 4. Wheeled conveyances drawn by horses, ambulance wagons. The forms of all these conveyances have been lately revised by a committee which was appointed in 1868 by Sir J. Pakington, Then Secretary of State for War, to inquire into the general question of ambulance and hospital conveyances for the army and the new pattern vehicles have now been authorized for use. (T. L.)
This article was written by Sir Thomas Longmore (1816-95), Surgeon General, C.B., F.R.C.S.E., served in Crimea; Professor of Army Surgery, Netley (from 1863); Hon. Surgeon to Queen Victoria (from 1868); author of Treatise on Gunshot Wounds; Treatise on Ambulances; and Sanitary Condition of the British and French Armies in the Crimea.