The word ambulance, from the Latin ambulare, meaning to walk or move from place to place, was applied to the French hôpital ambulant by Surgeon Dominique-Jean Larrey during the Napoleonic Wars. Larrey referred to "temporary hospital establishments, organized near the divisions of an army, to follow their movements and to assure early succor to the wounded." He and later Europeans included wagons, drivers, surgeons, supplies, and all material support within the meaning of the term.

Decades later, British Surgeon General Thomas Longmore explained in the ninth edition of the Encyclopaedia Britannica (1875) that ambulances, in military parlance, were "hospital establishments moving with armies in the field, and organized for providing early surgical assistance to the wounded after battles." His definition differed little from that provided by Larrey. Essentially, ambulances were intended to provide temporary assistance to the wounded, thus distinguishing them from stationary or fixed hospitals, where the sick and wounded received care and treatment "of a more permanent character." Nevertheless, according to Longmore, the term ambulance in American and British usage was frequently misapplied to the two- or four-wheeled "ambulance wagon" or wheeled-transport conveyance, which carried wounded from the battlefield to temporary and fixed hospitals. Thus, while the term six ambulances typically referred to six field hospitals attached to the army and moving with it, in England and America it also meant six wagons. As late as 1909, Lieutenant Colonel William G. Macpherson, writing in the Journal of the Royal Army Medical Corps on medical support and organization, warned against calling an ambulance wagon an ambulance. For him, an ambulance was "a mobile medical unit, and it must be used to express the unit only" Notwithstanding this intent, the British and American corruption of the word, growing out of the experiences and language of the Crimean and American Civil wars, confused usage to the extent that both meanings have prevailed into the present day. In this book, I trace both histories, from their origin, through the Great War, and into its aftermath.

Any study of the ambulance, however defined, cannot be viewed apart from military science, military hygiene and sanitation, military surgery, and military-medical administration. The effects of technology and organization on the moving and supplying of armies; changes in military strategy from close-order volley firing in linear platoons to artillery and open-order skirmishes; the development of breech-loading rifled cannon, high-velocity small arms, explosive shells, shrapnel, hand grenades, and bombs; and the introduction of railroads challenged the very assumptions on which planners built their medical evacuation systems. The same proved true of motorized vehicles and of offensive measures, such as gas attacks and air raids.

Timely and effective evacuation of wounded not only avoided the permanent loss of a soldier's services but maintained the morale of those who remained to fight. Clearly, when soldiers faced the prospect of abandonment by their officers and comrades, they were less willing to fight. In addition, it eliminated the likelihood that able-bodied soldiers would leave the firing line to assist wounded comrades to safety. The presence of hospitals near the field of battle also reflected an intent by the military to return the wounded soldier to his unit as quickly as possible. In other words, the farther back the wounded were evacuated, the less likely they were to return to their units. Finally, an efficient system of medical evacuation maintained morale on the home front.

The time available to collect, treat, and distribute wounded soldiers to appropriate medical facilities weighed heavily as medical planners sought to adjust their evacuation systems to new strategies and technologies to wars of movement versus stationary wars, and to the competing needs of replacement troops and matériel that demanded access to the same roads and transport. Each battle had its own set of dynamics and its own decision points: whether to collect the more seriously wounded first or to leave them to the enemy during retreat; whether to risk ambulance bearers in open engagements, when improved weaponry made them more vulnerable, or to leave the casualties to collect in "nests" until night or a lull in the battle; whether to risk doctors and surgeons close to the front line in a stationary war or to rely on an efficient transport system to convey the wounded to ambulance stations further to the rear; whether to treat gunshot wounds and fractures on the basis of aseptic treatment or to consider every wound infected. As history has shown, the answers often meant the difference between well-ordered, life-preserving relief to the wounded and demoralizing debacles that wasted lives and destroyed armies and nations. Paul Bronsart von Schellendorff (1832-91) remarked in his Duties of the General Staff (1895) that "the system of evacuating sick forms the basis of the entire medical service in the field." Like links in a chain, the failure of one link nullified the ability of the others to perform their functions. When the system failed, for whatever reason, the military faced the harshness of public condemnation.

I have chosen to give greater emphasis to the development of British and American evacuation procedures and technology than to those of other nations. Notwithstanding this preference, this history is a seam within a much broader cloth. This has meant drawing broad comparisons and contrasts, looking for elements of continuity from one war or nation to another, and demonstrating common problems. The interested reader should also understand that, while a number of different wars are included in this study, my intent has not been to cover all aspects of medical evacuation or, for that matter, to give equal treatment to all developments. To do so would have required writing several books or expanding the present study beyond what I had originally intended. For that reason, hospital ships are treated more peripherally than are hand conveyances, wheeled vehicles, and other types of ground transportation. The emphasis on immediate ground transportation and medical evacuation systems highlights the common dilemmas that faced the victorious and the defeated on the battlefield, the revolutionary challenges to the old order, the irksome internal conflicts confronting planners and sanitarians, the impact of new technology, and the persistence of old problems in new situations. By focusing primarily on hand conveyances and wheeled vehicles, I have been able to recount with greater force and clarity what, for many nations and their armies, were common problems, incongruities, and acknowledged controversies. All too often, the sick and wounded were sacrificed to a military Moloch without reason, without intelligence, and without compassion. Yet, along with the martial chorus that heralded the beginnings of the modern Leviathan state, there was also born a desire to bring help and dignity to the sick and wounded in war.

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