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There were some high-level discussions in Britain when the RAF committed to bombing cities in 1941-42. Some scientists argued that not only was bombing incapable of causing catastrophic economic damage to Germany, but the morale effects were unlikely to match anticipations. This was based on a survey of residents of (I think) Birmingham and Hull, who were hit heavily during the Blitz, and their resilience. There was also discussion of the effects of bombing in Abyssinia, of Japan in China, and in Spain. Most subsequent discussion revolved around the anticipated effects on the war effort, but in the minutes of a high-level meeting in November 1942, we find this argument:

“There was, however, one strong argument in favour of this heavy air offensive which had not yet been mentioned; piecemeal devastation of German cities would bring the horrors of home to the German people in a way that had not hitherto been possible. They might in this way be made to realise that aggression did not pay.”

That sort of argument would tend to negate the importance of the British experience. Of course, these questions have been debated for many decades, and the general consensus seems to be that British bombing policy was mainly a function of prewar doctrines anticipating the devastating effects of bombing, which were entrenched in the politics of the RAF as an independent service; and in the imperative to show support to the Soviets. Updated studies of the effects of bombing would generally have been subordinated to those established motivations.

In the American case, I’ve run into a July 1945 study by political scientist Quincy Wright , “Historical Studies of Casualties,” which attempted to correlate casualty counts with capitulation in historical wars. Wright had already published a macro-historical comparative study of wars in 1942, A Study of War . I’m pretty sure this sort of study was inconsequential for policy, but it suggests that, at this time, the social-political dynamics of war were considered a pressing, unresolved problem, certainly academically.

In a notorious incident, the RAND Corporation later studied the circumstances of capitulation , including under what circumstances the US might consider capitulation – when this was learned by Congress, there were moves to defund the Air Force’s RAND contract.

Anyway, these are all isolated data points in a much larger picture of historical thought that remains to be synthesized. But it seems like something that can be profitably brought into the picture here.

March 7, 2015 at 9:21 am

On your point about whether, by issuing a demonstration, the US would have been delineating an ethical line, which they might later be forced to cross in an indefensible way, I don’t quite see things the same way.

My sense has always been that the US-British response to the style of war in World War II – and particularly direct attacks on civilians – was that this kind of war was immoral, but that it had become necessary to avoid greater evil.

While LM stenosis is a potentially attractive target for PCI because of its large diameter and proximal position in the coronary circulation, two important pathophysiological features may mitigate against the success of PCI: (i) up to 80% of LM disease involves the bifurcation known to be at particularly high risk of restenosis; and (ii) up to 80% of LM patients also have multivessel CAD where CABG, as already discussed, may already offer a survival advantage.

The most ‘definitive’ current account of treatment of LM disease by CABG or PCI is from the hypothesis-generating subgroup analysis of the SYNTAX trial. In 705 randomized LM patients, the 1-year rate of death (4.4% vs. 4.2%; P = 0.88), CVA (2.7% vs. 0.3%; P = 0.009), MI (4.1% vs. 4.3%; P = 0.97), repeat revascularization (6.7% vs. 12.0%; P = 0.02) and MACCE (13.6% vs. 15.8%; P = 0.44) only favoured CABG for repeat revascularization, but at a higher risk of CVA.

By SYNTAX score terciles, MACCE rates were 13.0% vs. 7.7% ( P = 0.19), 15.5% vs. 12.6% ( P = 0.54), and 12.9% vs. 25.3% ( p = 0.08) for CABG vs. PCI in the lower (0–22), intermediate (23–32), and high (≥33) terciles, respectively. Unpublished data at 2 years show respective mortalities of 7.9% and 2.7% ( P = 0.02) and repeat revascularization rates of 11.4% and 14.3% ( P = 0.44) in the two lower terciles, implying that PCI may be superior to CABG at 2 years. Of note, among the 1212 patients with LM stenosis included in the registry or in the RCTs, 65% had SYNTAX scores ≥33.

Support for the potential of PCI at least in lower risk LM lesions comes from several other sources. In a meta-analysis of 10 studies, including two RCTs and the large MAIN-COMPARE registry, of 3773 patients with LM stenosis, Naik et al. [ 56 ] reported that there was no difference between PCI and CABG in mortality or in the composite endpoint of death, MI, and CVA up to 3 years, but up to a four-fold increase in repeat revascularization with PCI. These results were confirmed at 5 years in the MAIN-COMPARE registry [ 57 ].

The two issues to be addressed are:

the appropriateness of revascularization ( Table 8

Table 8
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Indications for revascularization in stable angina or silent ischaemia

Table 8
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Indications for revascularization in stable angina or silent ischaemia

the relative merits of CABG and PCI in differing patterns of CAD ( Table 9

Table 9
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Indications for coronary artery bypass grafting vs. percutaneous coronary intervention in stable patients with lesions suitable for both procedures and low predicted surgical mortality

Table 9
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Indications for coronary artery bypass grafting vs. percutaneous coronary intervention in stable patients with lesions suitable for both procedures and low predicted surgical mortality

Current best evidence shows that revascularization can be readily justified:

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