Pediatric Burns By Bradley J. Phillips

and civilian fire disasters.^3-5 In 1916, Sir Harold Gillies, who is recognized as the founder of modern plastic surgery, returned from service in France during WWI to establish the first plastic and oral-maxillofacial surgery service in the United Kingdom, treating combat casualties, including burn patients, at Cambridge Military Hospital, Aldershot. Gillies proceeded to develop forward-deployed units during WWII to care for patients with burns and other injuries meriting plastic surgical attention.⁶ His cousin, Archibald McIndoe, became consultant in plastic surgery to the Air Ministry and established a burn hospital at East Grinstead during the Battle of Britain in 1940. One of McIndoe’s most important contributions was his recognition of the need for a social support system for burn survivors, which was provided for these airmen not only by their own “Guinea Pig Club,” but also by hospital staff and local townspeople. McIndoe condemned the use of tannic acid for topical wound care, defined the need for early rehabilitation, and developed techniques for facial reconstruction based on experience with 600 patients with severe facial burns.^7,8 He later recalled his state of mind upon embarking on this uncharted path: “A good, competent surgeon, experienced, yes…but when I looked at a burned boy for the first time and saw I must replace his eyelids, God came down my right arm.”⁹

Even though no dedicated burn unit was employed for the care of US combat casualties during WWII, that conflict nonetheless accelerated the development of burn care in the United States, just as in England. The Japanese attack on Pearl Harbor generated several hundred burn casualties,¹⁰ propelled the United States into war, and was followed in January 1942 by a National Research Council symposium on burns, with the initiation of several research programs in burn care. Two such federally funded programs were in place at the Massachusetts General Hospital (MGH) (in burn and complex wound infections and in the physiology of burns) when, on November 28, 1942, a fire at the Cocoanut Grove nightclub in Boston killed 492 of approximately 1000 occupants.¹¹ One hundred fourteen patients arrived at MGH within a 2-hour period, of whom 39 survived to be admitted to a special casualty ward which remained open till December 13. The hospital course of these 39 patients was carefully documented, and although MGH did not establish a permanent burn unit at the time, these observations (which ranged from fluid resuscitation and management of inhalation injury to social work and rehabilitation) formed a foundation for subsequent research.¹²

Dr Chester Keefer, who supervised the US national program to evaluate penicillin, released enough of the new drug to Dr Champ Lyons, a young surgeon at Massachusetts General Hospital, to treat 13 of the 39 burn patients.¹³ Dr Lyons authored the microbiology chapter in the Cocoanut Grove burns monograph, in which he remarked on the benign nature of the burn wounds of patients who received penicillin.¹⁴ In the spring of 1943, Dr Lyons became a major in the US Army’s Surgical Consultants and began a study of penicillin in the treatment of soldiers with complicated orthopedic injuries at the Bushnell General Hospital in Brigham, Utah.¹⁵ In June 1943, a second clinical unit to study penicillin was established at Halloran General Hospital on Staten Island, New York. Dr Lyons was placed in charge of the Wound Unit’s study of penicillin, in the course of which 209 combat casualties were treated with the new drug. After completing the studies at Halloran General Hospital, Lyons was reassigned to the Surgical Consultants Division, a new addition to the Army Medical Department. He served as surgical infections and wound management consultant in the Mediterranean theater of operations, where he continued to refine methods of penicillin usage.¹⁵

In 1947, the Wound Unit was relocated from Staten Island to Fort Sam Houston, Texas, and renamed the Surgical Research Unit (SRU).¹⁶ In this unit, patients with infected burns and other infected wounds were treated on a special ward at Brooke General Hospital.¹⁷ Two years later (1949), due to growing concerns about the possibility of nuclear war with the Soviet Union and recognition (based on experience in Japan) that such a war could generate thousands of burn survivors, the SRU established the nation’s second burn unit and refocused its research effort from the evaluation and use of antibiotics to the treatment of burns.¹⁸

Organization of the Burn Unit

The organization and subsequent development of the SRU was one of the US Army’s most important contributions to burn care. Under a single commander and within a small organization separate from the host military, hospital surgeons, physicians, basic scientists, therapists, nurses, enlisted medics, and support personnel were brought together. The members of this prototypical multidisciplinary burn team had one objective: to improve patient outcomes by conducting integrated basic and clinical research. That is, they sought to take problems from the clinic to the laboratory, where models of injury were developed and the solutions were then transferred back to the clinic and applied to patient care. Along with a growing number of civilian burn units, the SRU (later the US Army Institute of Surgical Research, USAISR) made numerous contributions, several of which are discussed later. Also critical for improving care in the United States was the unit’s commitment to training surgeons, many of whom became directors of civilian burn centers.^19-21 Finally, designation of the unit as a single destination for all US military burn casualties, as