Wartime Hospital Trains Have a Track Record of Success

Editor’s note: This article is based on the second-place winning entry in the 2024 History of Surgery Poster Competition, which occurred in conjunction with Clinical Congress.

In February 2022, Russia invaded Ukraine, launching the largest assault on a European country since World War II. As combat erupted along the Russia- Ukraine border, frontline healthcare facilities faced compromised integrity and functionality. While the military evacuated uniformed personnel, civilians with injuries or preexisting medical conditions continued to require transportation and clinical management.

Confronted with an escalating crisis, authorities turned to a time-tested means of evacuation—the hospital train.¹ Outfitting railcars with more than 200 patient beds, a basic operating theater, pharmacy, dining center, and quarters for health workers reflected a broader trend of adaptability and innovation during wartime. This article traces the development and use of hospital trains from the 19th to the 21st century, relying on contemporary military medical documents from each conflict to unravel this history.

Advent of Hospital Trains

The Crimean War, a conflict between Russia and an alliance of the United Kingdom, France, Turkey, and Sardinia (1853–1856), represents the first use of military railroads in a major conflict. In 1855, after a fatal first winter, the British government financed the construction of a railway network across the Crimean Peninsula to ensure the dependable delivery of supplies and munitions to military posts.² Transportation by railway quickly proved highly advantageous, enabling the fast, safe, and large-scale movement of goods.

Shortly thereafter, the British and French armies loaded the returning empty trains with injured soldiers in need of evacuation. The military railway transported hundreds of soldiers daily, functioning as the first hospital trains. Although transportation on hospital trains was undoubtedly faster, it initially offered little in the way of comfort. Early hospital railcars were improvised cattle or freight cars padded with straw, pine needles, or blankets for cushioning during turbulent transportation. Ventilation was poor, and windows were often nonexistent, leaving soldiers in pain within a jostling dark box for miles.

Introducing Purpose-Designed Railcars

Hospital trains were first deployed in North America during the early battles of the American Civil War (1861–1865), when control of the railways provided a significant military advantage. At that time, travel on the hospital train—also known as an ambulance train—continued to cause significant discomfort for the wounded. Efforts to improve these conditions led military forces to outfit passenger cars, rather than cattle or cargo cars, and employ dedicated medical attendants.

Later additions included integrating pharmacists, dressing stations, kitchens, and even mobile operating theaters. However, not all innovations were effective and safe. In 1864, Harper’s Weekly described an attempt to improve the train’s bumpy ride by suspending litters using India-rubber bands attached to metal rods, an arrangement that likely proved downright dangerous.

Renovating passenger coaches for medical care required significant time and effort. During the US Civil War, governments collaborated with railway companies to build purpose-designed railway carriages, ready for deployment as hospital trains. These models featured enlarged doorways for easy passage, formal patient beds with mattresses and bedding, and designated sleeping quarters for healthcare personnel.³

When traveling, hospital trains were generally marked with red flags to be seen during the day and red lights at night. During the course of the Civil War, more than 20,000 Union and Confederate wounded soldiers were transported by railway.⁴

Reuse, Recycle, and Reboard

Hospital trains continued to reappear in major and minor conflicts during the next century. In almost every instance, passenger trains were adapted until sufficient purpose-built hospital trains were manufactured. During the Spanish-American War (1898), for example, hospital trains were created out of modified Pullman sleeping cars, with the dining car functioning as the kitchen. These modified trains could transport up to 240 patients, two physicians, and 22 enlisted military staff at one time.⁵

The use of hospital trains expanded significantly during World War I, becoming the primary means of transporting wounded soldiers across Europe.⁶ At the beginning of the war, this mode of evacuating patients once again consisted of repurposed railcars. Military contractors stripped the interiors of the coaches, painted them white, covered the floors in linoleum and lead, and fastened pull-down cots to the walls. They designed the beds to be removed and used as stretchers if the need arose.

To maximize space, the dining cars featured collapsable tables, enabling healthcare providers to add more beds and increase the train’s carrying capacity at a moment’s notice.⁷

Water was warmed with gas heaters and moved through a steaming system for heat. Ventilation was achieved through the use of large electric fans, with ample circulation prioritized, especially in ward cars and lavatories. Equipment was sterilized using a steam jet.

In many cases, trains received aid at each stop in the form of reserve blankets, medical supplies, and clothing from the American Red Cross. Even when railcars were not configured as hospital trains, the railways transported soldiers, supplies, and equipment. For example, soldiers who did not need advanced wound care, such as those diagnosed with tuberculosis, were often transported in standard passenger cars.

Whether with passenger cars or modified mobile hospitals, the railways are credited with transporting large numbers of soldiers from the forward combat zones to rear healthcare facilities. For example, during the Battle of the Somme in 1916, more than 33,000 British soldiers were evacuated across France in just 4 days using ambulance trains.

These trains often operated well beyond their intended capacity during this battle, largely due to the high-casualty rate.⁸ Medical trains were routinely pushed beyond capacity limits. With high numbers of wounded soldiers, US Hospital Train No. 18 evacuated more than 10,000 patients between July and September 1918. During the course of World War I, British hospital trains evacuated 3.4 million Allied troops in Europe.³

Contemporary accounts from Army Nurse Corps personnel stationed on World War I hospital trains described working on board railway cars as treating a “parade of faces.”⁹ Their work embodied intimate yet transient care, as patients were treated in their most vulnerable moments before evacuation to base hospitals.

Hospital Trains after the Great War

Despite the emergence of airplane evacuation in the 1920s and 1930s, trains remained a primary mode for transporting the wounded in the European Theater during World War II due to their ability to ferry more patients with higher efficiency over longer distances in any weather conditions. In 1944, Germany’s Battle of the Bulge offensive forced the rapid, unplanned evacuation of Allied patients. The 57th Hospital Train participated in this massive effort, and the healthcare workers even wrote a song about their work.

57th Hospital Train Song

The rolling 57th rolls along the track
Bringing all our wounded boys safely back
Valiantly they fought
Homeward they are brought
On, the rolling 57th rolls along.

Chorus
Rolls along, rolls along
Oh, the rolling 57th rolls along
We will feed them pills
To chase away their ills

Oh, the rolling 57th rolls along
We’re all kept busy running up and down the aisle
Changing all their dressings in the latest style
They have done their part
It’s time for us to start
Oh, the rolling 57th rolls along

The use of hospital trains continued into the Cold War with the US Army strategically placing hospital trains throughout Germany in preparation for a potential Soviet invasion.

Unfortunately, one location where the US Army did not stockpile rolling assets was the Korean Peninsula. During the Korean War, casualties from frontline battalion aid stations flooded clearing centers and prompted the expansion of military hospital train detachments. Wooden Korean coach cars from circa 1860 were converted into railway ambulances.¹⁰ Makeshift litters lined the walls, and accommodations lacked comfort, not unlike the early Civil War trains.

Rather than relying on air evacuation, which was often hindered by multiple factors such as poor weather, casualty numbers exceeding transport capacities, and technical barriers, the majority of casualties during the Korean War were transported by trains (or trucks) from forward Mobile Army Surgical Hospitals to rear zones for further support and care.^10,11 Eventually, the US shipped purpose-built ambulance railcars to the Korean Peninsula and deployed them in combat, replacing their improvised precursors.

No other transportation modality can evacuate casualties as quickly, efficiently, safely, and comfortably as hospital trains. Given the track record of these trains, it is not surprising that Ukraine returned to medical train transportation in 2022. Partnering with Doctors Without Borders, the government implemented a hospital train system capable of providing both basic and intensive care, evacuating nearly 2,500 patients between March and November 2022.¹

The deployment of hospital trains has been most extensive when three conditions have converged: significant casualty volumes necessitating mass evacuation, established railway infrastructure, and contested or neutral airspace. Military conflict creates conditions conducive to the use of train ambulances. Given an increasingly unstable world, hospital trains likely will remain integral to future emergency response.

Alexandria Soto is a third-year medical student at Duke University School of Medicine in Durham, NC.

References

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4. Hawk A. An ambulating hospital or how the hospital train transformed Army medicine. Civil War History. 2002;48(3):197-219.
5. Richard C. The Army hospital train during the Spanish-American War. Proceedings of the Association of the Military Surgeons of the United States, 1899. 1900;VIII:196-202.
6. Ford JH. The division of hospitalization continued-Medical Department transportation. In: Ireland MW, ed. The Medical Department of the United States Army in the World War. US Army Surgeon General’s Office; 1927.
7. Clark H. American hospital trains in France. Medical Times. 1918;XLVL(5):117-119.
8. . Kay A. Somme 2016: Ambulance trains of World War 1 meant the difference between life and death. All About History: The National Railway Museum. July 2016. Available at: https://www.historyanswers.co.uk/history-of-war/somme-2016-the-ambulance-trains-of-world-war-1-meant-the-differencebetween-life-and-death/. Accessed January 27, 2025.
9. Croshere M. Hospital train number 58: Nursing at the front. J Christ Nurs. Spring 1997;14(2):28,46.
10. Smith OD. The hospital train-evacuation workhorse. Med Bull US. Feb 1953;1(3):38-39.
11. Barr J, Montgomery S. Helicopter medical evacuation in the Korean War: Did it matter? J Trauma Acute Care Surg. Jul 2019;87(1S Suppl 1):S10-S13.