FEW modern surgical texts have been as contentious as “War Surgery in Iraq and Afghanistan”. Rumours of its graphic content were circulating in surgical circles well before the book came out. The American military censors reportedly tried to have the book refused an ISBN code, which would have prevented it being sold commercially. A retired US Army surgeon general said the military command was concerned that the book's graphic images “could be spun politically to show the horrors of war”.

Horrors there are: the shredding lacerations of blast; cavitating high-velocity ballistic wounds; injuries from “biological projectiles” formed of body fragments from other victims dismembered in explosions. Civilian casualties include children riddled with shrapnel and a pregnant woman shot through her belly. Each case is laid out in detail; the raw verity of digital photographs from the operating table beside surgical notes written up in the immediate aftermath of resuscitation. The book's publication earlier in the summer coincided with complaints by American news photographers that they were being refused access to combat operations lest they depict American casualties.

There has never been a surgical reference like it, for several reasons. Throughout the text are graphic colour photographs: phosphorus bursts white against black sky, a Humvee aflame on a bleak highway. The section on “high energy orthopaedic polytrauma” (high-velocity multiple bone injuries) places a scan of a shattered pelvis beside a close-up of a belt of machine-gun bullets, highlighting the irony of striving to save life in the moral vacuum of war.

The book's introduction categorises different types of casualties and the care that is available to them. For example, American soldiers and “embedded” American journalists (such as Bob Woodruff of ABC News, who has written in the foreword about his own experience of being wounded) receive optimal treatment at each step through the military medical and rehabilitation system. Enemy combatants, who are denied the protection of the Geneva Convention, are treated in American military hospitals until they are fit enough to be transferred to Bagram air base or Guantánamo Bay. “Host-nation nationals”, Iraqi and Afghan soldiers and civilians, receive emergency care before being passed back to whatever facilities exist in their own health services. “The dichotomy of different pathways of care for American versus host-nation casualties”, observes the introduction, “remains an ongoing challenge.”

The diversity of cases makes the book unique as a reference of war surgery practice. The collection of wound data by the Borden Institute, the co-publisher, and the rigorous analysis of response to injury, allow prompt assessment of treatment and resuscitation techniques. In the course of the fighting in Iraq and Afghanistan the number of deaths that result from haemorrhage has been hugely reduced by improved tourniquets, new compounds to stop bleeding and fundamental changes in the types of fluids transfused to treat shock. New surgical approaches to complex injuries are being rapidly evaluated and applied. The book is dense—about the size and mass of the chest-plate in a set of body armour—and will save many lives. “War Surgery in Afghanistan and Iraq” should be part of every front-line surgeon's armoury.