“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. wound is like nothing they’ve seen, even in a Manhattan emergency room. 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 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.

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 American 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,” Dr. Lounsbury said. Instead, they try to bring it up to just 80 or 90 with red cells and extra platelets, which encourage clotting.

Image UNDER KEVLAR Life-threatening injuries can occur even when armor and helmets prevent penetration. Credit... From “War and Surgery in Afghanistan and Iraq”

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.