By DONALD G. McNEIL Jr.

The pictures show shredded limbs, burned faces, profusely bleeding wounds. The subjects are mostly American soldiers, but they include Iraqis and Afghans, some of them young children.
They appear in a new book, “War Surgery in Afghanistan and Iraq: A Series of Cases, 2003-2007,” quietly issued by the United States Army - the first guidebook 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 battlefield doctors are clinical, but the gruesome photographs illustrate the grim nature of today’s wars, in which more are hurt by explosions than by bullets, and body armor leaves many alive but maimed.
And the cases detail important advances in treating blast amputations, massive bleeding, bomb concussions and other front-line trauma.
But “War Surgery” is not easy to find. There were strenuous efforts within 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 combat areas for depicting dead and wounded Americans. But efforts to censor the book were overruled by successive Army surgeons general.
“I’m ashamed to say that there were folks even in the medical department who said, Over my dead body will American civilians see this,” said Dr. David E. Lounsbury, one of the book’s three authors. Dr. 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,” Dr. 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 I.E.D. [improvised explosive device] wound is like nothing they’ve seen, even in a Manhattan emergency room. It’s a shocking, heartstopping, 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 show wounds riddled 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.
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,” Dr.
Lounsbury said. Instead, they try to bring it up to just 80 or 90 with red cells and extra platelets, which encourage clotting.
Neurosurgeons are also treating blast victims by quickly removing large sections 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.
Amputations have also changed. Dr. Lounsbury’s brother lost both legs and an arm in Vietnam, and in those days clean “guillotine” amputations were done as high as possible.
Now surgeons try to preserve as much bone and flesh as they can, even if the stump is unsightly. Modern prosthetics are molded to it.
And when morphine is not enough, nerve blocks - internal drips of local anesthetic, often given by a small pump held by the patient - have become common in pain control.
Military censors suggested numerous changes, including removing photos showing burning vehicles and the faces of any American wounded. But the authors argued that the book was dedicated to soldiers and marines and that the wounded were proud to be identified as such.
All whose faces were fully shown had given written permission, they said. If it was not obtained, patients’ eyes were covered with black bars.
Kevin C. Kiley, the Army’s surgeon general when the book was being prepared, said some high ranking officials in the military had been worried that the pictures “could be spun politically to show the horrors of war.”
“The counterargument to that, which I concurred with,” Dr. Kiley said, “was that this is a medical textbook that could save lives.
Dr. Stephen P. Hetz, a retired colonel and co-author, said that he always had faith that the book would ultimately not be suppressed.
There was never any doubt in my mind that the Army would publish this,” he said.“It was just a matter of getting around the nitwits.”