The history of the ambulance begins in ancient times, with the use of carts to transport patients. Ambulances were first used for emergency transport in 1487 by the Spanish forces during the siege of Málaga by the Catholic monarchs against the Emirate of Granada, and civilian variants were put into operation in the 1830s. Advances in technology throughout the 19th and 20th centuries led to the modern self-powered ambulance.
Early patient transport
There is evidence of forced transport of those with psychiatric problems or leprosy in ancient times. The earliest record of such an ambulance was probably a hammock-based cart constructed around 900 AD by the Anglo-Saxons.
During the Crusades of the 11th century, the Knights Hospitaller set up hospitals to treat pilgrims wounded in their battles in the Holy Land, although there is no clear evidence to suggest how the wounded made their way to these hospitals.
The Normans used a litter suspended between horses on two poles. Variations on the horse litter and horse-drawn wagons were used until the 20th century.
Early battlefield treatment
The first record of ambulances being used for emergency purposes relates to the troops of Isabella I of Castile in 1487. The Spanish army of the time was well treated and attracted volunteers from across the continent; and among their benefits were the first military hospitals (ambulancias), although injured soldiers were not picked up for treatment until after the cessation of the battle, resulting in many dying on the field.
A major change in usage of ambulances in battle came about with the ambulances volantes designed by Dominique Jean Larrey (1766–1842), who later became Napoleon Bonaparte’s chief physician. Larrey was present at the battle of Spires,The French Army of the Rhine under the command of Custine captured Speyer on 30 September 1792. between the French and Prussians, and was distressed that wounded soldiers were not picked up by the numerous ambulances (which regulations required to be stationed two and a half miles back from the scene of battle) until after hostilities had ceased, so he set about developing a new ambulance system. Having decided against using the Norman system of horse litters, he settled on two- or four-wheeled horse-drawn wagons to transport fallen soldiers from the (active) battlefield after they had received early treatment in the field. Larrey adapted the axle assembly from the French army's horse-drawn artillery ("flying artillery" – ) that made their gun carriages especially maneuverable on uneven terrain, and so christened his ambulances "flying ambulances" (ambulances volantes). The flying ambulances were first used by the Army of the Rhine in 1793. Larrey subsequently developed similar services for Napoleon's armies, and adapted his ambulances to the conditions; including developing a litter which could be carried by a camel for the 1798–1801 French campaign in Egypt.
Development of civilian services
In civilian ambulances, a major advance was made with the introduction of a transport carriage for cholera patients in London in 1832. The Times newspaper said, "The curative process commences the instant the patient is put in to the carriage; time is saved which can be given to the care of the patient; the patient may be driven to the hospital so speedily that the hospitals may be less numerous and located at greater distances from each other".
Advances during the American Civil War
More advances in medical care for the military were made during the United States’ Civil War. Union military physicians Joseph Barnes and Jonathan Letterman built upon Larrey’s work and designed a prehospital care system for soldiers, which used new techniques and methods of transport. They ensured that every regiment possessed at least one ambulance cart, with a two-wheeled design that accommodated two or three patients. These ambulances proved to be too lightweight for the task, and were phased out to be replaced by the "Rucker" ambulance, named for Major General Rucker, which was a four-wheeled design, and was a common sight on the battlefield. Other vehicles were pressed into service during the civil war, including a number of steamboats, which served as mobile hospitals for the troops. It was during this period that the practice of transporting wounded soldiers to treatment facilities by railroad was introduced.
Hospital-based services begin
The first known hospital-based ambulance service was based out of Commercial Hospital, Cincinnati, Ohio, (now the University of Cincinnati Medical Center) by 1865. This was soon followed by other services, notably the New York service provided out of Bellevue Hospital. Edward Dalton, a former surgeon in the Union Army, was charged with creating a hospital in lower New York; he started an ambulance service to bring the patients to the hospital faster and in more comfort, a service which started in 1869. These ambulances carried medical equipment, such as splints, a stomach pump, morphine, and brandy, reflecting contemporary medicine. Dalton believed that speed was of the essence, and at first the horses were kept in harness while awaiting a call: within a few months this practice had been replaced with a 'drop,' or 'snap,' harness arrangement, whereby the tack was lowered by pulley from the ceiling straight onto the horse: under either scheme, ambulances were ready to go within 30 seconds of being called.Ryan Corbett Bell (2009), The Ambulance: A History. McFarland & Co., . The service was very popular and grew rapidly, with the year 1870 seeing the ambulances attend 1401 emergency calls, but twenty-one years later, this had more than tripled to 4392. For the first week of their operation, the ambulances were crewed by the hospital's house-staff, after which the hospital hired Drs. Duncan Lee and Robert Taylor as full-time ambulance surgeons; going forward, the plan was to crew the ambulances with fresh graduates of Bellevue's surgical training program, who would serve for six-month terms and be replaced by new hires from successive graduating classes. This scheme foundered immediately, however, when graduates balked at the schedule and the salary offered: $50 a month, twelve-hour shifts, and one day off every four weeks. Instead, by the end of 1869, the system of staffing the ambulance with residents in training (who could simply be assigned, rather than having to be recruited) was firmly established. As late as 1935, these interns were earning the same $50 a month their grandfathers would have received.
In 1867, the city of London's Metropolitan Asylums Board, in the United Kingdom, received six horse-drawn ambulances for the purpose of conveying smallpox and fever patients from their homes to a hospital. These ambulances were designed to resemble private carriages, but were equipped with rollers in their floors and large rear doors to allow for a patient, lying on a specially designed bed, to be easily loaded. Space was provided for an attendant to ride with the patient, and the entire patient compartment was designed to be easily cleaned and decontaminated. Anyone willing to pay the cost of horse hire could summon the ambulance by telegram or in person.
Dedicated services begin In 1880, the President of the Liverpool Medical Institution, Reginald Harrison, suggested a horse-drawn ambulance for the city. In 1884, this ambulance service was created based at the Liverpool Northern Hospital: it was the first in Britain.
In June 1887 the St John Ambulance Brigade was established to provide first aid and ambulance services at public events in London. It was modelled on a military-style command and discipline structure. The St John Ambulance Association had already been teaching first aid to the public for 10 years prior to that. National or state based branches of St John Ambulance now provides ambulance and first aid services in many countries around the world.
On 6 June 1891, the first ambulance station in Poland and the second in Europe was established in Kraków, modeled on similar services in Vienna. Founded by local physicians and fire officials, it initially operated horse-drawn ambulances before later adopting motor vehicles.
In Ireland the St John Ambulance was set up in 1903 in the Guinness Brewery in St. James Gate in Dublin by Doctor, later Sir, John Lumsden for workers. In 1910 the Brigade began its first public duty at the Royal Dublin Society. During the 1916 rising and (after becoming the independent St. John Ambulance Brigade of Ireland) the 'Emergency' (World War II) the brigade acted as an ambulance service and remained so until the set up of Regional Ambulance Services.
In 1938 the Order of Malta Ambulance Corps was set up in Galway. In the years since this voluntary service has gone from strength to strength and is now Ireland's largest voluntary ambulance service and one of Ireland's largest charities.
In Queensland, Australia, military medic Seymour Warrian called a public meeting in Brisbane and established an ambulance service after witnessing an event at the Brisbane showgrounds during Show Week in 1892. A fallen rider, suffering a broken leg was walked off the field by well-meaning but misguided bystanders, worsening his injury. As a result of the meeting, the Queensland Ambulance Transport Brigade was formed on the 12 September. The first ambulance station in Queensland operated out of the Brisbane Newspaper Company and officers on night duty slept on rolls of newspaper on the floor. They had a stretcher, but no vehicle and transported patients on foot, although in time, they gained horse-drawn stretchers and eventually vehicles. A year after the establishment of the Brisbane centre, another was established in Charters Towers in north Queensland, growing to over 90 community controlled ambulance centres. In 1991 the independent QATB centres amalgamated to form the Queensland Ambulance Service which is now the fourth largest ambulance service in the world.
Mass transit use for emergency medical provision
In the late 19th century St Louis, Missouri, United States started using a trolley car on their tram network designed to act as an ambulance, transporting the sick and injured. The design of the tram network in St Louis was such that the ambulance streetcar, introduced in 1894, was able to reach all 16 infirmaries in the city. Introduced in 1913, trolley cars in Bahia, Brazil, included a fumigating compartment and a two-bed nurses work area.
In Germany, in 1902, a civilian ambulance train was introduced (building on the use of trains during military conflict) for use during railway accidents. It housed a mobile operating room and eight stretchers. Railroad employed surgeons lived near the railway station where the ambulance train was stationed, and were summoned to urgently attend in the event of an emergency. This train had priority over the tracks, with all other trains obliged to give way.
Introduction of motor units
In the late 19th century, the automobile was being developed, and started to be introduced alongside horse-drawn models; early 20th-century ambulances were powered by steam, gasoline, and electricity, reflecting the competing automotive technologies then in existence. However, the first motor-powered ambulance was brought into service in the last year of the 19th century, with the Michael Reese Hospital, Chicago, taking delivery of the first automobile ambulance, donated in February 1899 by 500 prominent local businessmen. This was followed in 1900, by New York City, which extolled its virtues of greater speed, more safety for the patient, faster stopping and a smoother ride. These first two automobile ambulances were electrically powered with motors on the rear axle.