AT BAGRAM AIR BASE, AFGHANISTAN Bleeding to death has always been the chief hazard of war wounds - and the control of bleeding the first task of the combat surgeon. Ambroise Pare knew that 460 years ago.

A French physician who treated some of the first combat wounds caused by firearms, Pare observed in 1550 that when amputating a limb there was less bleeding if blood vessels were tied off with silk thread rather than cauterized with a hot iron. For that and other gentler practices he became known as the "father of surgery."

Pare's professional descendants are still obsessed with bleeding.

The improvements in the care of casualties that have come out of the Iraq and Afghanistan wars almost all involve hemorrhage, the medical term for bleeding. They include better ways to stop it, keep it from restarting, and reverse it by restoring blood to the circulation (an option not available to Pare). They Improvements in treating hemorrhage are the main reason survival of battlefield casualties is so much greater now than in the past.

Data presented at a conference in August revealed that 8.8 percent of the U.S. combat casualties in Iraq and Afghanistan died, either on the battlefield or later of wounds. That compares with 16.5 percent of the Vietnam War's casualties and 22.8 percent of World War II's.

A different analysis compared battlefield injuries that occurred between 2003 and 2006. Those in the later year were more severe on average than those in 2003, but mortality wasn't significantly greater. For the subset of "blast injuries" - the most common cause of trauma - wounds in 2006 were more extensive, severe and likely to take a soldier permanently out of service than those of 2003. But they weren't more likely to be fatal.

The conclusion: Medical treatment has gotten better over the nine-year course of the wars.

Almost none of the improvement is the consequence of new drugs or new devices. Most of it, ironically, involves old technology and old practices that fell out of favor in the past 50 to 100 years and have been rediscovered and improved.

And nearly all of them involve blood.

After Mogadishu



The modern focus on battlefield hemorrhage came out of the disastrous military operation in Somalia in 1993 chronicled in the book and movie "Black Hawk Down."

Over a 15-hour period, about 170 U.S. soldiers were involved in a battle in the narrow streets of Mogadishu where they'd gone to capture a Somali warlord. Helicopters crashed, soldiers were trapped and fired on by civilians, and rescuers got lost. More than 100 troops were wounded, 14 died on the battlefield, and four died later at hospitals.

Several years after the event, military physicians analyzed every serious injury and death that occurred. They wanted to learn whether any could have been prevented, or if any of the care had unwittingly led to more casualties.