MANHATTAN DWELLERS ARE FAMILIAR WITH THE SOUND OF SIRENS echoing down the steel canyons in the middle of the night. What most don’t realize is that their forebears were some of the first in the country to be awakened in this way, though in the nineteenth century the sound would have been a foot-pedaled bell and the clatter of steel-banded wagon wheels.

A single horse would draw this black vehicle, modeled on a stagecoach and with the word “Ambulance” stenciled in gold letters on its side. This initial fleet of ambulances was staffed with some of the country’s first medical interns, who served 12-hour shifts, and was stocked with the first aid kit of the day: tourniquets, splints, bandages, a stomach pump and straps to immobilize fractured limbs, with handcuffs and a straitjacket for good measure. Also in tow: a quart of brandy—used as an emergency stimulant at the time. Ambulances would carry their passengers to Bellevue, a booming public hospital that at the time was the nation’s largest.

People have used litters, carts or chariots to carry injured soldiers from battlefields since antiquity. Ambulances first transported civilians, however, in the early 1800s, when Great Britain devised “fever vans” to take suspected cases of diptheria, cholera or other infectious diseases to hospitals. Cincinnati’s Commercial Hospital debuted an ambulance service in 1865, yet it was the vehicles of Bellevue Hospital, which hit New York City streets in 1869, that became the standard-bearer for fleets of the era.

Edward Dalton, who had graduated from New York’s College of Physicians and Surgeons and then interned at Bellevue, designed the service. A former Civil War surgeon, he undoubtedly had experience with “gut busters,” rough-riding wagons that the Union Army used to haul injured men from the fields of war. Dalton had been appointed to serve as a sanitary superintendent with the newly formed Board of Health for New York City when he proposed the idea of civilian ambulances. The city’s fetid, disease-ridden tenements and chaotic, muddy streets—war zones in their own right where people died in agony for lack of a means to get to a hospital—inspired his innovation.

Dalton’s scheme called for an “ambulance barn,” with light, high wagons on call around the clock that mercifully featured a suspension system and a padded floor. A horse waited in harness, ready to move; drop-harnesses hung from the ceiling ready to drape quickly on to the next animal. The early patient roster included those who’d had mishaps with a milk wagon and a street car, victims of bludgeonings and people who had attempted suicide with straight razors and a butcher knife. The police also began a time-honored tradition of summoning ambulances to clear inebriates off the streets.

The Bellevue ambulance fleet drew praise citywide following its fast, tenacious response to the so-called Orange Riots of 1870 and 1871, in which Catholic and Protestant Irish-Americans fought each other with cudgels and bricks. The carriages raced to and from the scene of the carnage, depositing bloodied combatants at Belluvue’s door, or in its morgue. By the early 1890s, Bellevue’s ambulances had carried some 4,400 people, and the invention had been taken up around the world.

Today, the race is on to make the ambulance an even more robust extension of the hospital. Many ambulances can transmit real-time patient information, including video, so that staff waiting for a hand-off in the emergency room can begin their work. Other ambulances now specialize, bringing targeted care to the scene of the crisis. Isolation transport vehicles employ sealed chambers for patients suspected of having a deadly infection. Brightly colored pediatric ambulances include isolettes and air equipment for newborns and DVD systems to soothe children.

A mobile stroke unit, which debuted in Homburg, Germany, in 2008, shaves precious minutes in stroke treatment by enabling technicians to begin assessment and treatment the moment they arrive. It is equipped with a CT scanner, stroke medications and other specialized equipment. Each vehicle costs from $600,000 to $1 million to purchase and another $1 million annually to operate. There are less than two dozen in use in the United States.

And while the horseless ambulance was a great step forward, a much-discussed near-future innovation—driverless, or autonomous, ambulances—has been less universally embraced. Proponents say that these vehicles might reduce the estimated 4,500 traffic accidents per year involving emergency vehicles. But in a survey of emergency services technicians, most said they would be reluctant to work in a self-driving ambulance, and research shows that about half of all U.S. adults would be squeamish about riding in one, even in an emergency. Now, as in the 1870s, faith in the ambulance rests on those who sit behind the wheel.