'war surgery in afghanistan and iraq: a series of cases, 2003-2007'

The image show shredded limbs, burned faces, abundantly bleeding lesion. The topic are largely American GIs, but they include Iraqis and Afghans, some of them young kid.

They appear in a new book, "War Surgery in Islamic State of Afghanistan and Iraq: A Series of Cases, 2003-2007," softly issued by the U.S. Army - the first guide of new techniques for American battlefield surgeons to be published while the wars it analyzes are still being fought.

Its 83 case descriptions from 53 battleground doctors are clinical and bone-dry, but the gruesome photographs illustrate the grim nature of today's wars, in which more are hurt by explosions than by slug, and body armor leave of absence many alive but wounded.

And the cases item important advances in treating blast amputations, massive hemorrhage, bomb concussions and other front-line injury.

Though it is expensively produced and includes a preface by the ABC letter writer Bob sweet woodruff, who was badly wounded by a wayside bomb in 2006, "War Surgery" is not easy to find. There were strenuous efforts inside the army over the last year to censor the book and keep it out of civilian hands.

Paradoxically, the book is being issued as news photographers complain that they are being ejected from armed combat areas for depiction dead and maimed Americans.

But attempt to censor the book were overruled by successive U.S. Army surgeons general. It can be ordered from the authorities Printing business office for $71; virago.com lists it as out of stock, but the Borden Institute, the army checkup office that published it, said one thousand more transcript would be printed.

"I'm ashamed to say that there were folks even in the checkup department who said, 'Over my dead body will American civilians see this,"' said David Lounsbury, one of the three writer. Lounsbury, 58, an internist and retired colonel, took part in the 1991 and 2003 invasions of Iraq and was the editor of military medicine textbooks at Walter Reed Army Medical Center.

"The average Joe Surgeon, civilian or military, has never seen this stuff," Lounsbury said. "Yeah, they've seen guys shot in the chest. But the kind of ferocious blast, burn and penetrating trauma that's part of the modern IED wound is like nothing they've seen, even in a Manhattan emergency room," using the initials for what the Pentagon calls an "improvised explosive device," or roadside bomb. "It's a shocking, heart-stopping, eye-opening kind of thing. And they need to see this on the plane before they get there, because there's a learning curve to this."

The pictures of wounded children include some of a 5-year-old shot in a vehicle trying to run through a checkpoint. Other pictures show wounds enfiladed with dirt, genitals severed by a roadside bomb, a rib - presumably that of a suicide bomber - driven deep into a soldier's body, and the tail of an unexploded rocket protruding from a soldier's hip.

There are moments that reflect the desperation in the invaded country: an Afghan in the jaw-locked rictus of tetanus after home-treating a foot blown off by a landmine. And moments that reflect the modern U.S. Army: a soldier with unexplained pelvic pain that turns out to be a life-threatening ectopic pregnancy.

The book was created to teach techniques that surgeons adopted, abandoning old habits.

For example, they no longer pump saline into a patient with massive trauma to try to get the blood pressure back up to 120. "You do that, you end up with a highly diluted, cold patient with no clotting factors, and the high pressure restarts bleeding," Lounsbury said. Instead, they try to bring it up to just 80 or 90 with red cells and extra platelets, which encourage clotting.

Also, initial surgery even on a severely wounded patient may be brief - just enough to control hemorrhaging and prevent contamination by a torn bowel. Then the patient is returned to intensive care to warm up, raise the blood pressure and restore the electrolyte balance. The next operation is usually just enough to stabilize the patient for transport to a more sophisticated hospital, perhaps in Baghdad or Kabul, in Germany or the United States.

The book describes a surgeon who erred fatally by trying to do too much - a four-hour operation on a soldier who had lost a leg to a roadside bomb. The effort drained the forward hospital's blood bank and the patient died on the helicopter to the next hospital.

Also, neurosurgeons treating a blast victim now quickly remove a large section of the skull to relieve pressure, even if no shrapnel has penetrated. Such patients are sometimes able to walk and talk after a blast but then collapse and die as their brain swells.