1004 American Family Physician www.aafp.org/afp Volume 92, Number 11 ◆ December 1, 2015

An elevated white blood cell count has many potential etiologies, including malignant and nonmalignant causes. It is important to use age- and pregnancy-specific normal ranges for the white blood cell count. A repeat complete blood count with peripheral smear may provide helpful information, such as types and maturity of white blood cells, uniformity of white blood cells, and toxic granulations. The leukocyte differential may show eosinophilia in parasitic or allergic conditions, or it may reveal lymphocytosis in childhood viral illnesses. Leukocytosis is a common sign of infection, particularly bacterial, and should prompt physicians to identify other signs and symptoms of infection. The peripheral white blood cell count can double within hours after certain stimuli because of the large bone marrow stor- age and intravascularly marginated pools of neutrophils. Stressors capable of causing an acute leukocytosis include surgery, exercise, trauma, and emotional stress. Other nonmalignant etiologies of leukocytosis include certain medi- cations, asplenia, smoking, obesity, and chronic inflammatory conditions. Symptoms suggestive of a hematologic malignancy include fever, weight loss, bruising, or fatigue. If malignancy cannot be excluded or another more likely cause is not suspected, referral to a hematologist/oncologist is indicated. (Am Fam Physician. 2015;92(11):1004-1011. Copyright © 2015 American Academy of Family Physicians.)

Evaluation of Patients with Leukocytosis LYRAD K. RILEY, MD, and JEDDA RUPERT, MD, Eglin Air Force Base Family Medicine Residency, Eglin Air Force Base, Florida

L eukocytosis, often defined as an ele- vated white blood cell (WBC) count greater than 11,000 per mm3 (11.0 × 109 per L) in nonpregnant adults,

is a relatively common finding with a wide differential. It is important for clinicians to be able to distinguish malignant from non- malignant etiologies, and to differentiate between the most common nonmalignant causes of leukocytosis.

Leukocytosis in the range of approxi- mately 50,000 to 100,000 per mm3 (50.0 to 100.0 × 109 per L) is sometimes referred to as a leukemoid reaction. This level of elevation can occur in some severe infections, such as Clostridium difficile infection, sepsis, organ rejection, or in patients with solid tumors.1 Leukocytosis greater than 100,000 per mm3 is almost always caused by leukemias or myeloproliferative disorders.2

Normal Variation The normal range for WBC counts changes with age and pregnancy (Table 1).3 Healthy newborn infants may have a WBC count from 13,000 to 38,000 per mm3 (13.0 to 38.0 × 109 per L) at 12 hours of life (95% confidence interval). By two weeks of age, this decreases to approximately 5,000 to 20,000 per mm3 (5.0 to 20.0 × 109 per L), and gradually declines throughout childhood to reach adult levels of 4,500 to 11,000 per mm3

(4.5 to 11.0 × 109 per L; 95% confidence interval) by about 21 years of age.3 There is also a shift from relative lymphocyte to neu- trophil predominance from early childhood to the teenage years and adulthood.4 During pregnancy, there is a gradual increase in the normal WBC count (third trimester 95% upper limit = 13,200 per mm3 [13.2 × 109 per L] and 99% upper limit = 15,900 per mm3 [15.9 × 109 per L]), and a slight shift toward an increased percentage of neutrophils.5 In one study of afebrile postpartum patients, the mean WBC count was 12,620 per mm3 (12.62 × 109 per L) for women after vaginal deliveries and 12,710 per mm3 (12.71 × 109 per L) after cesarean deliveries. Of note, pos- itive bacterial cultures were not associated with leukocytosis or neutrophilia, making leukocytosis an unreliable discriminator in deciding which postpartum patients require antibiotic therapy.6 Patients of black African descent tend to have a lower WBC count (by 1,000 per mm3 [1.0 × 109 per L]) and lower absolute neutrophil counts.7

Normal Leukocyte Life Cycle and Responses The life cycle of leukocytes includes devel- opment and differentiation, storage in the bone marrow, margination within the vas- cular spaces, and migration to tissues. Stem cells in the bone marrow produce cell lines

CME This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions on page 977.

Author disclosure: No rel- evant financial affiliations.

Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2015 American Academy of Family Physicians. For the private, noncom- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.

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of erythroblasts, which become red blood cells; megakaryoblasts, which become plate- lets; lymphoblasts; and myeloblasts. Lym- phoblasts develop into various types of T and B cell lymphocytes. Myeloblasts further differentiate into monocytes and granulo- cytes, a designation that includes neutro- phils, basophils, and eosinophils (Figure 1). Once WBCs have matured within the bone marrow, 80% to 90% remain in storage in the bone marrow. This large reserve allows for a rapid increase in the circulating WBC count within hours. A relatively small pool (2% to 3%) of leukocytes circulate freely in the peripheral blood1; the rest stay depos- ited along the margins of blood vessel walls or in the spleen. Leukocytes spend most of their life span in storage. Once a leukocyte is released into circulation and peripheral tis- sues, its life span ranges from two to 16 days, depending on the type of cell.

Differentiation by Type of White Blood Cell Changes in the normal distribution of types of WBCs can indicate specific causes of leukocytosis (Table 2).8 Although the differential of the major types of WBCs is important for evaluating the cause of leu- kocytosis, it is sometimes helpful to think in terms of absolute, rather than relative, leukopenias and leukocytoses. To calculate the absolute cell count, the total leukocyte count is multiplied by the differential per- centage. For example, with a normal WBC count of 10,000 per mm3 (10.0 × 109 per L) and an elevated monocyte percentage of 12, the absolute monocyte count is 12% or 0.12 times the WBC count of 10,000 per mm3, yielding 1,200 per mm3 (1.2 × 109 per L), which is abnormally elevated.

The most common type of leukocytosis is neutrophilia (an increase in the absolute number of mature neutrophils to greater than 7,000 per mm3 [7.0 × 109 per L]), which can arise from infections, stressful condi- tions, chronic inflammation, medication use, and other causes (Table 3).1-7,9,10 Lymphocy- tosis (when lymphocytes make up more than 40% of the WBC count or the absolute count is greater than 4,500 per mm3 [4.5 × 109

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Leukocytosis greater than 100,000 per mm3 (100.0 × 109 per L) is almost always caused by leukemias or myeloproliferative disorders.

C 2

Leukocytosis is not a reliable indicator of postpartum bacterial infection.

C 6

Patients with leukocytosis and no other signs of systemic inflammatory response syndrome do not require blood cultures.

C 19

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited- quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Table 1. White Blood Cell Count Variation with Age and Pregnancy

Patient characteristic Normal total leukocyte count

Newborn infant 13,000 to 38,000 per mm3 (13.0 to 38.0 × 109 per L)

Infant two weeks of age 5,000 to 20,000 per mm3 (5.0 to 20.0 × 109 per L)

Adult 4,500 to 11,000 per mm3 (4.5 to 11.0 × 109 per L)

Pregnant female (third trimester) 5,800 to 13,200 per mm3 (5.8 to 13.2 × 109 per L)

Information from reference 3.

Figure 1. White blood cell maturation. The life cycle of leukocytes includes development and differentiation, storage in bone marrow, margination within vascular spaces, and migration to tissues.

Megakaryoblast

Platelets

Erythroblast

Erythrocyte

Myeloblast

Basophil Eosinophil Neutrophil Monocyte

Stem cell

Lymphoblast

Lymphocyte

B o

n e

m ar

ro w

B lo

o d

IL LU

ST R

A TI

O N

B Y

D A

V E

K LE

M M

Leukocytosis

1006 American Family Physician www.aafp.org/afp Volume 92, Number 11 ◆ December 1, 2015

per L]) can occur in patients with pertussis, syphilis, viral infections, hypersensitivity reactions, and certain subtypes of leukemia or lymphoma. Lymphocytosis is more likely to be benign in children than in adults.4 Epstein-Barr virus infection, tuberculosis or fungal disease, autoimmune disease, sple- nectomy, protozoan or rickettsial infections, and malignancy can cause monocytosis (monocytes make up more than 8% of the WBC count or the absolute count is greater than 880 per mm3 [0.88 × 109 per L]).8

Eosinophilia (eosinophil absolute count greater than 500 per mm3 [0.5 × 109 per L]),

Table 3. Nonmalignant Causes of Neutrophilia

Cause Distinguishing features Evaluation

Patient characteristics

Pregnancy, obesity, race, age Reference appropriate WBC count by age or pregnancy trimester

Compare WBC count to recent baseline (if available)

Infection Fever, system-specific symptoms

Physical examination findings

Obtain system-specific cultures and imaging (e.g., sputum cultures, chest radiography)

Consider empiric antibiotics

Consider use of other biomarkers, such as CRP and procalcitonin

Reactive neutrophilia

Exercise, physical stress (e.g., postsurgical, febrile seizures), emotional stress (e.g., panic attacks), smoking

Confirm with history

Chronic inflammation

Rheumatic disease, inflammatory bowel disease, granulomatous disease, vasculitides, chronic hepatitis

Obtain personal and family medical history

Consider erythrocyte sedimentation rate and CRP levels, specific rheumatology laboratories

Consider subspecialist consultation (e.g., rheumatology, gastroenterology)

Medication induced

Corticosteroids, beta agonists, lithium, epinephrine, colony-stimulating factors

Confirm with history; consider discontinuation of medication, if warranted

Bone marrow stimulation

Hemolytic anemia, immune thrombocytopenia, bone marrow suppression recovery, colony- stimulating factors

Complete blood count differential; compare with baseline values (if available)

Examine peripheral smear

Consider reticulocyte and lactate dehydrogenase levels

Consider flow cytometry, bone marrow examination, hematology/ oncology consultation

Splenectomy History of trauma or sickle cell disease Confirm with history

Congenital Hereditary/chronic idiopathic neutrophilia, Down syndrome, leukocyte adhesion deficiency

Obtain family, developmental history

Consider hematology/oncology, genetics, and immunology consultations

NOTE: After patient characteristics, causes are listed in approximate order of frequency.

CRP = C-reactive protein; WBC = white blood cell.

Information from references 1 through 7, 9, and 10.

Table 2. Normal White Blood Cell Distribution

White blood cell line

Normal percentage of total leukocyte count

Neutrophils 40 to 60

Lymphocytes 20 to 40

Monocytes 2 to 8

Eosinophils 1 to 4

Basophils 0.5 to 1

Information from reference 8.

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although uncommon, may suggest allergic conditions such as asthma, urticaria, atopic dermatitis or eosinophilic esophagitis, drug reactions, dermatologic conditions, malig- nancies, connective tissue disease, idiopathic hypereosinophilic syndrome, or parasitic infections, including helminths (tissue par- asites more than gut-lumen parasites).11,12 Isolated basophilia (number of basophils greater than 100 per mm3 [0.1 × 109 per L]) is rare and unlikely to cause leukocytosis in isolation, but it can occur with allergic or inflammatory conditions and chronic myelogenous leukemia13 (Table 4).

Nonmalignant Etiologies A reactive leukocytosis, typically in the range of 11,000 to 30,000 per mm3 (11.0 to 30.0 × 109 per L), can arise from a variety of etiologies. Any source of stress can cause a catecholamine-induced demargination of WBCs, as well as increased release from the bone marrow storage pool. Examples include surgery, exercise, trauma, burns, and emo- tional stress.9 One study showed an average increase in WBCs of 2,770 per mm3 (2.77 × 109 per L) peaking on postoperative day 2 after knee or hip arthroplasty.10 Medications known to increase the WBC count include corticosteroids, lithium, colony-stimulating factors, beta agonists, and epinephrine. Dur- ing the recovery phase after hemorrhage or hemolysis, a rebound leukocytosis can occur.

Leukocytosis is one of the hallmarks of infection. In the acute stage of many bacte- rial infections, there are primarily mature and immature neutrophils (Figure 2); sometimes, as the infection progresses, there is a shift to lymphocyte predominance. The release of less- mature bands and metamyelocytes into the peripheral circulation results in the so-called “left shift” in the WBC differential. Of note, some bacterial infections paradoxically cause neutropenias, such as typhoid fever, rickett- sial infections, brucellosis, and dengue.1,14 Viral infections may cause leukocytosis early in their course, but a sustained leukocytosis is not typical, except for the lymphocytosis in some childhood viral infections.

An elevated WBC count is a suggestive, but not definitive, marker of the presence of

significant infection. For example, the sen- sitivity and specificity of an elevated WBC count in diagnosing acute appendicitis are 62% and 75%, respectively.15,16 For diagnos- ing serious bacterial infections without a

Table 4. Selected Conditions Associated with Elevations in Certain White Blood Cell Types

White blood cell line Conditions that typically cause elevations

Basophils Allergic conditions, leukemias

Eosinophils Allergic conditions, dermatologic conditions, eosinophilic esophagitis, idiopathic hypereosinophilic syndrome, malignancies, medication reactions, parasitic infections

Lymphocytes Acute or chronic leukemia, hypersensitivity reaction, infections (viral, pertussis)

Monocytes Autoimmune disease, infections (Epstein-Barr virus, fungal, protozoan, rickettsial, tuberculosis), splenectomy

Neutrophils Bone marrow stimulation, chronic inflammation, congenital, infection, medication induced, reactive, splenectomy

Figure 2. Neutrophilia postsplenectomy with sepsis. An 18-year-old woman with distal pancreatectomy and splenectomy for benign pancreatic pseudopapillary tumor two weeks earlier presents to the emergency department with a temperature of 103°F (39.4°C), leuko- cytosis with bandemia, tachycardia, and urinalysis results consistent with infection. White blood cell count = 57,100 per mm3 (57.1 × 109 per L), hemoglobin = 12.6 g per dL (126 g per L), platelet count = 832,000 per mm3 (832 × 109 per L). White blood cell differential: 75.4% seg- mented cells, 19.3% bands. Note neutrophils (arrows) with < 3 lobes to nuclei (band cells).

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1008 American Family Physician www.aafp.org/afp Volume 92, Number 11 ◆ December 1, 2015

source in febrile children, the discrimina- tory value of leukocytosis is less than that of other biomarkers, such as C-reactive protein or procalcitonin.17 Although a WBC count greater than 12,000 per mm3 (12.0 × 109 per L) is one of the criteria for the systemic inflammatory response syndrome (or sepsis when there is a known infection), leukocy- tosis alone is a poor predictor of bacteremia and not an indication for obtaining blood cultures.18,19

Other acquired causes of leukocytosis include functional asplenia (predominantly lymphocytosis), smoking, and obesity. Patients with a chronic inflammatory condi- tion, such as rheumatoid arthritis, inflam- matory bowel disease, or a granulomatous disease, may also exhibit leukocytosis. Genetic causes include hereditary or chronic idiopathic neutrophilia and Down syndrome.

Malignant Etiologies Leukocytosis may herald a malignant dis- order, such as an acute or chronic leukemia (Figure 3), or a myeloproliferative disorder, such as polycythemia vera, myelofibrosis, or essential thrombocytosis. A previous article on leukemia in American Family Physician reviewed the features and differentiation of malignant hematopoietic disorders.20 Many solid tumors may lead to a leukocytosis in the leukemoid range, either through bone marrow involvement or production of gran- ulocyte colony-stimulating or granulocyte- macrophage colony-stimulating factors1,3,21 (Figure 4). Chronic leukemias are most com- monly diagnosed after incidental findings of leukocytosis on complete blood counts in asymptomatic patients. Patients with fea- tures suggestive of hematologic malignancies require prompt referral to a hematologist/ oncologist (Table 5).3,22

Approach to Evaluation A systematic approach to patients with leu- kocytosis includes identifying historical clues that suggest potential causes (Figure 5). Fever and pain may accompany infections or malignancies; other constitutional symp- toms, such as fatigue, night sweats, weight loss, easy bruising, or bleeding, might suggest

Figure 3. Lymphocytosis in a 70-year-old woman with a history of chronic lymphocytic leukemia presenting to the emergency depart- ment with a five-day history of subjective fevers, sore throat, and cough. White blood cell count = 147,500 per mm3 (147.5 × 109 per L), hemoglobin = 8.8 g per dL (88 g per L), platelet count = 82,000 per mm3 (82 × 109 per L). White blood cell differential: 96.6% lympho- cytes (monomorphic). Note many mature lymphocytes (small nuclei near the size of a red blood cell with thin rim cytoplasm; black arrows) and many smudge cells (white arrows).

Figure 4. Eosinophilia in malignancy in a 76-year-old man with a his- tory significant for metastatic prostate cancer presenting for che- motherapy. White blood cell count = 26,600 per mm3 (26.6 × 109 per L), hemoglobin = 10.8 g per dL (108 g per L), hematocrit = 32.6%. White blood cell differential: 51.8% eosinophils, 36.8% neutrophils, 6% lymphocytes, 4.5% monocytes, 0.9% basophils. Note eosinophils (arrows).

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December 1, 2015 ◆ Volume 92, Number 11 www.aafp.org/afp American Family Physician 1009

malignancy.22 Previous diagnoses or comor- bid conditions that cause chronic inflam- mation should be noted, as well as recent stressful events, medication use, smoking status, and history of splenectomy or sickle cell anemia. A history of an elevated WBC count is important, because duration will help determine the likely cause. Leukocy- tosis lasting hours to days has a different differential diagnosis (e.g., infections, acute leukemias, stress reactions) than a case that persists for weeks to months (e.g., chronic inflammation, some malignancies).

The physical examination should note erythema, swelling, or lung findings sug- gestive of an infection; murmurs suggestive of infective endocarditis; lymphadenopathy suggestive of a lymphoproliferative disor- der; or splenomegaly suggestive of chronic myelogenous leukemia or a myeloprolifera- tive disorder; petechiae or ecchymoses; or

painful, inflamed joints suggestive of con- nective tissue disease or infection.

Initial laboratory evaluation should include a repeat complete blood count to confirm the elevated WBC level, with differ- ential cell counts and a review of a peripheral blood smear. The peripheral smear should be examined for toxic granulations (suggestive of inflammation), platelet clumps (which may be misinterpreted as WBCs), the pres- ence of immature cells, and uniformity of the WBCs. On evaluation of a leukocytosis with lymphocyte predominance, a monomorphic population is concerning for chronic lym- phocytic leukemia, whereas a pleomorphic (varying sizes and shapes) lymphocytosis is suggestive of a reactive process.4,23 With all forms of leukocytosis, concurrent abnor- malities in other cell counts (erythrocytes or platelets) suggest a primary bone mar- row process and should prompt hematology/ oncology evaluation.

As indicated by the history and examina- tion findings, physicians should consider performing cultures of blood, urine, and joint or body fluid aspirates; rheumatol- ogy studies; a test for heterophile antibod- ies (mononucleosis spot test); and serologic titers. Radiologic studies may include chest radiography (to identify infections, some malignancies, and some granulomatous dis- eases) and, as indicated by history, computed tomography or bone scan. If hematologic malignancy is suspected, additional confir- matory testing may include flow cytometry, cytogenetic testing, or molecular testing of the bone marrow or peripheral blood.

Data Sources: The primary literature search was completed using Essential Evidence Plus and included searches of the Cochrane, POEM, and NICE guideline databases using the search term leukocytosis. In addition, PubMed searches were performed using the terms leu- kocytosis and white blood cell. Search dates: October 31 and December 17, 2014, and September 2015.

The authors thank Melissa King, MD, Department of Hematology/Oncology, Eglin Air Force Base Hospital, for reviewing the manuscript, and Niquanna Perez, Eglin Air Force Base laboratory services, for procuring peripheral smear images.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. government, the Department of Defense, or the U.S. Air Force.

Table 5. Findings Suggestive of Hematologic Malignancies in the Setting of Leukocytosis

Symptoms

Bruising/bleeding tendency

Fatigue, weakness

Fever > 100.4°F (38°C)

Immunosuppression

Night sweats

Unintentional weight loss

Physical examination findings

Lymphadenopathy

Petechiae

Splenomegaly or hepatomegaly

Laboratory abnormalities

Decreased red blood cell count or hemoglobin/hematocrit levels

Increased or decreased platelet count

Monomorphic lymphocytosis on peripheral smear

Predominantly immature cells on peripheral smear

White blood cell count > 30,000 per mm3 (30.0 × 109 per L), or > 20,000 per mm3 (20.0 × 109 per L) after initial management

Information from references 3 and 22.

Leukocytosis Evaluation of Leukocytosis

Figure 5. Algorithm for the evaluation of leukocytosis. (ANA = antinuclear antibodies; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate.)

Leukocytosis (white blood cell count > 11,000 per mm3 [11.0 × 109 per L])

Repeat complete blood count

Order peripheral smear

Leukocytosis confirmed?

Obtain additional history and perform physical examination

Leukocytosis explained by history or patient characteristics (e.g., pregnancy, newborn, splenectomy, smoking, medications)?

No further workup necessary

No further workup necessary Patient presents with:

Weight loss, fatigue, night sweats, fevers

Abnormal red blood cell and platelet count

Immature leukocyte forms (blasts)

Chronic duration (weeks or years)

History of or risk factors for malignancy, splenomegaly, lymphadenopathy, bruising?

Consider malignancy:

Hematology/oncology consultation

Consider additional testing to include flow cytometry, cytogenetic testing, or molecular testing of the bone marrow or peripheral blood

Consider nonmalignant etiologies

Which cell line is affected?

No Yes

No Yes

No Yes

Basophilia (> 100 per mm3 [0.1 × 109 per L]; rare):

Search for malignancy (or allergic condition, much less likely)

Monocytosis (> 880 per mm3 [0.88 × 109 per L]):

Infections (Epstein-Barr virus, tuberculosis, fungal, protozoan, rickettsial)

Autoimmune disease

Splenectomy

Consider:

Sick contact, surgical, and travel history

Imaging (chest radiography)

Pathogen-specific testing (mononucleosis spot test, purified protein derivative)

ESR, CRP, and ANA measurement

Neutrophilia (> 7,000 per mm3 [7.0 × 109 per L]):

Infection

Chronic inflammation

Recent stressors

Medication induced

Bone marrow stimulation

Splenectomy

Tobacco use

(see Table 3)

Consider:

Medical, medication, family, travel, sick contact, surgical, and social history

ESR, CRP, and ANA measurement

Pathogen isolation (blood cultures, lumbar puncture)

Additional imaging (system-specific)

Lymphocytosis (> 4,500 per mm3 [4.5 × 109 per L]):

Infections (viral, pertussis)

Hypersensitivity reaction

Consider:

Sick contact and immunization history

Imaging (chest radiography)

Pathogen-specific testing (viral panels)

Eosinophilia (> 500 per mm3 [0.5 × 109 per L]):

Allergic conditions

Eosinophilic esophagitis

Medication reactions

Dermatologic conditions

Parasitic infections

Consider:

Medication, travel history

Full skin examination

Skin biopsy, if warranted

Allergy/immunology testing

Parasite-specific testing (stool ova and parasites)

Upper endoscopy

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December 1, 2015 ◆ Volume 92, Number 11 www.aafp.org/afp American Family Physician 1011

The Authors

LYRAD K. RILEY, MD, is a faculty member at the U.S. Air Force Eglin Family Medicine Residency Program, Eglin Air Force Base, Fla., and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences School of Medicine, Bethesda, Md.

JEDDA RUPERT, MD, is a second-year resident at the U.S. Air Force Eglin Family Medicine Residency Program.

Address correspondence to Lyrad K. Riley, MD, Eglin AFB Family Medicine Residency, 307 Boatner Rd., Eglin Air Force Base, FL 32542 (e-mail: [email protected]). Reprints are not available from the authors.

REFERENCES

1. Cerny J, Rosmarin AG. Why does my patient have leu- kocytosis? Hematol Oncol Clin North Am. 2012;26(2): 303-319, viii.

2. Jain R, Bansal D, Marwaha RK. Hyperleukocytosis: emergency management. Indian J Pediatr. 2013;80(2): 144-148.

3. Hoffman R, Benz EJ Jr, Silberstein LE, Heslop H, Weitz J, Anastasi J. Hematology: Basic Principles and Practice. 6th ed. Philadelphia, Pa.: Elsevier/Saunders; 2013:table 164-20.

4. Chabot-Richards DS, George TI. Leukocytosis. Int J Lab Hematol. 2014;36(3):279-288.

5. Lurie S, Rahamim E, Piper I, Golan A, Sadan O. Total and differential leukocyte counts percentiles in normal pregnancy. Eur J Obstet Gynecol Reprod Biol. 2008; 136(1):16-19.

6. Dior UP, Kogan L, Elchalal U, et al. Leukocyte blood count during early puerperium and its relation to puer- peral infection. J Matern Fetal Neonatal Med. 2014; 27(1):18-23.

7. Lim EM, Cembrowski G, Cembrowski M, Clarke G. Race-specific WBC and neutrophil count reference intervals. Int J Lab Hematol. 2010;32(6 pt 2):590-597.

8. Berliner N. Leukocytosis and leukopenia. In: Goldman L, Schafer AI, eds. Goldman’s Cecil Medicine. 24th ed. Philadelphia, Pa.: Elsevier/Saunders; 2012.

9. Iskandar JW, Griffeth B, Sapra M, Singh K, Giugale JM. Panic-attack-induced transient leukocytosis in a healthy male: a case report. Gen Hosp Psychiatry. 2011; 33(3):302.e11-302.e12.

10. Deirmengian GK, Zmistowski B, Jacovides C, O’Neil J, Parvizi J. Leukocytosis is common after total hip and knee arthroplasty. Clin Orthop Relat Res. 2011; 469(11):3031-3036.

11. Ustianowski A, Zumla A. Eosinophilia in the returning traveler. Infect Dis Clin North Am. 2012;26(3):781-789.

12. Cormier SA, Taranova AG, Bedient C, et al. Pivotal Advance: eosinophil infiltration of solid tumors is an early and persistent inflammatory host response. J Leu- koc Biol. 2006;79(6):1131-1139.

13. Munker R. Leukocytosis, leukopenia, and other reactive changes of myelopoiesis. In: Munker R, Hiller E, Glass J, Paquette R, eds. Modern Hematology: Biology and Clinical Management. 2nd ed. Totowa, N.J.; Humana Press; 2007.

14. Potts JA, Rothman AL. Clinical and laboratory features that distinguish dengue from other febrile illnesses in endemic populations. Trop Med Int Health. 2008;13(11): 1328-1340.

15. Yu CW, Juan LI, Wu MH, Shen CJ, Wu JY, Lee CC. Systematic review and meta-analysis of the diagnostic accuracy of procalcitonin, C-reactive protein and white blood cell count for suspected acute appendicitis. Br J Surg. 2013;100(3):322-329.

16. Van den Bruel A, Thompson MJ, Haj-Hassan T, et al. Diagnostic value of laboratory tests in identifying seri- ous infections in febrile children: systematic review. BMJ. 2011;342:d3082.

17. Yo CH, Hsieh PS, Lee SH, et al. Comparison of the test characteristics of procalcitonin to C-reactive protein and leukocytosis for the detection of serious bacterial infec- tions in children presenting with fever without source: a systematic review and meta-analysis. Ann Emerg Med. 2012;60(5):591-600.

18. Dellinger RP, Levy MM, Rhodes A, et al.; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving sepsis campaign: interna- tional guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637.

19. Coburn B, Morris AM, Tomlinson G, Detsky AS. Does this adult patient with suspected bacteremia require blood cultures? [published correction appears in JAMA. 2013;309(4):343]. JAMA. 2012;308(5):502-511.

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21. Granger JM, Kontoyiannis DP. Etiology and outcome of extreme leukocytosis in 758 nonhematologic cancer patients: a retrospective, single-institution study. Can- cer. 2009;115(17):3919-3923.

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Filed Under: Diplomacy and Foreign Relations • War and Military • 1929-1945: The Great Depression and World War II

Atomic Bombing of Japan Barbaric Tactic or Quick Way to End the War?

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The Issue

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The issue: Should the United States use the atomic bomb against Japan in an attempt to end World War II? Or should the United States pursue another course of action to end the war?

Arguments in favor of the use of the atomic bomb: Using the atomic bomb against Japan is the most effective means of bringing World War II to an end. All indications show that Japan will fight to the very last man, so a drastic course of action is needed. The main alternative to use of the bomb—a massive invasion of the Japanese home islands—would be far too costly in terms of U.S. soldiers' lives. By using the bomb, the United States can bring the war to a quick end and save tens of thousands, and perhaps hundreds of thousands, of U.S. lives.

Arguments against the use of the atomic bomb: The use of such a devastating weapon against a civilian population is immoral and barbaric. Also, the bombings are not necessary; indications show that Japan is pursuing peace negotiations, and the United States should allow more time for those negotiations to bear fruit. And in using an atomic weapon, the United States will spark a dangerous arms race with the Soviet Union.

Background

On April 24, 1945, less than two weeks after Harry Truman (D, 1945-53) assumed the presidency following the death of President Franklin Roosevelt (D, 1933-45), Secretary of War Henry Stimson wrote to him: "I think it is very important that I should have a talk with you as soon as possible on a highly secret matter.... [It] has such a bearing on our present foreign relations and has such an important effect upon all my thinking in this field that I think you ought to know about it without much further delay." Stimson would inform him of the development of an atomic bomb, and less than four months later Truman would have to decide whether to use it against Japan in an attempt to end World War II (1939-45).

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Truman did decide to use the bomb, perhaps one of the most momentous decisions in U.S. history. On August 6, 1945, at 8:15 a.m. (local time), the crew of the Enola Gay dropped an atomic bomb over the city of Hiroshima. The bomb detonated 2,000 feet above the center of Hiroshima, destroying 60 percent of the city (four square miles), and killing an estimated 70,000 to 100,000 people immediately. After the bombing, Truman described the attack as "only a warning of things to come."

Development of the atomic bomb began under the administration of President Franklin D. Roosevelt (left), and was completed under that of President Harry S. Truman (right). Hulton Archives/Getty Images; AFP/Getty Images

Indeed, three days later, a B-29 dropped a second atomic bomb over Nagasaki. The bomb exploded 1,540 feet above the city, killing an estimated 40,000 people and destroying two square miles of the city. Many more people in both Hiroshima and Nagasaki subsequently died of radiation-related illnesses. Altogether, an estimated 242,000 people died as a result of the Hiroshima and Nagasaki bombings.

The day after the Nagasaki bombing, Japan offered its surrender, and on August 14 Truman announced to the nation that Japan had surrendered. The treaty was formally signed in early September, bringing an end to World War II, during which the United States had suffered more than one million casualties, including 400,000 deaths.

Jeremy Eagle

At the time, it was widely accepted that the bomb was a necessary means to end the war and save the lives of thousands, or even hundreds of thousands, of U.S. soldiers. In a December 1945 Fortune magazine poll, just 5 percent of respondents said the United States should not have used the bomb, while 54 percent approved of what had been done and another 23 percent said they wished the United States had dropped more atomic bombs on Japan before its surrender.

However, there were some dissenting voices at the time. In the military, the atom bomb had not been unanimously viewed as the best way to end the war; alternative proposals for ending the war had included large-scale invasion of Japan, continued bombing of cities with conventional explosives, and continuation of a naval blockade to starve Japan into submission. In retrospect, several historians have challenged the need to drop the bomb, as well as the bomb's role in Japan's surrender.

Should President Truman have made the decision to drop the bomb on Hiroshima and Nagasaki? Or should he have followed another course of action to end the war? Were the Hiroshima and Nagasaki bombings immoral or necessary?

Supporters of the bombing say that it was the best course of military action. Although Japan was essentially defeated, they argue, all of the indications showed that the Japanese planned to fight to the last man. They point to heavy U.S. losses in battles in the months leading up to Japan's surrender. They also contend that Japan's surrender was unlikely because the allies were demanding unconditional surrender, including the removal of Emperor Hirohito from the throne. Japan had categorically refused to surrender if the emperor—who was accorded godlike status by the Japanese—was not allowed to remain on the throne.

Furthermore, proponents note, the main alternative to use of the atomic bomb being considered at the time was a mass invasion of the Japanese home islands. They contend that such an invasion would have been very costly in terms of U.S. lives. In using the bomb, supporters say, the United States brought the war to a quicker end, saving the lives of perhaps hundreds of thousands of U.S. soldiers.

Critics of the atomic bombing, on the other hand, argue that it was immoral and barbaric to use such a destructive weapon against a civilian population. They also contend that it was unnecessary because Japan was on the verge of defeat. Evidence shows that in the months leading up to the Hiroshima bombing, Japan was trying to get third parties involved in peace negotiations. Japan would have soon surrendered, they argue, if the United States had kept up with more conventional warfare and allowed time for those peace overtures to bear fruit.

Others criticize the United States for being the first to use an atomic weapon in warfare, ushering in the nuclear age. They argue that, in using the bomb, the United States sparked a dangerous nuclear arms race with the Soviet Union for most of the rest of the 20th century.

World War II and the Quest for Peace The United States entered World War II in 1941, two years after France and Britain jointly declared war against Nazi Germany. The war eventually expanded to include many other nations, including German allies Italy and Japan. The United States had resisted becoming militarily involved, but declared war on Japan on December 8, the

day after a Japanese surprise attack on Pearl Harbor naval base on the Hawaiian island of Oahu killed some 2,300 people. [See World War II and 'America First', Pearl Harbor Attack]

The war in Europe ended with Germany's surrender on May 7, 1945, but although Japan's navy and air force were largely defeated, Japan refused to surrender. In the early months of 1945, the United States was involved in several costly battles. In the fight on the Japanese island of Iwo Jima in February and March 1945, some 20,000 U.S. soldiers were killed, wounded, or missing in action; 41,000 Americans were either killed or wounded during the battle of Okinawa, which took place from April to June; and 31,000 troops were killed or injured in the battle of Luzon (in the Philippines) during the summer. The battles were even more costly for the Japanese; at Luzon, the Japanese suffered five casualties for every U.S. casualty.

As the war in the Pacific continued into the second half of 1945, the U.S. military was planning a large-scale invasion of Japan's home islands as a final push to end the war. Some 767,000 U.S. troops were scheduled to land on the southern island of Kyushu in November 1945 (in "Operation Olympic"). They would make Kyushu an air base for the second stage of the invasion ("Operation Coronet")—invading the main island of Honshu in March 1946 if Japan had not yet surrendered.

President Truman and other officials, however, were also weighing the possibility of using newly developed atomic bombs against Japan to force its surrender. The United States had begun a program to develop an atomic bomb after learning of Germany's efforts to do so in 1939. The United States accelerated those efforts after entering the war against Japan, and on July 16, 1945, the first U.S. atomic bomb was successfully tested. [See The Development of the Atomic Bomb (sidebar), Einstein's Letter to Roosevelt Regarding the Development of an Atomic Bomb (primary document)]

In July 1945, Truman, British prime minister Winston Churchill and Soviet leader Joseph Stalin met for a conference in Potsdam, Germany, to discuss post-war Europe and military options in Japan. While attending the Potsdam conference, Truman was informed of the successful test of the atomic bomb. On July 25, Truman and Stimson approved a written order for the use of the bomb against Japan. [See Description of the First U.S. Test of an Atomic Weapon (primary document), President Truman's Diary Entry Dated July 25, 1945 (primary document)]

The following day, the allies issued the Potsdam Declaration: While not specifically mentioning the atomic bomb, the declaration demanded that Japan surrender immediately or face "prompt and utter destruction." The allies insisted on Japan's unconditional surrender, which—although not specifically mentioned in the declaration — would include the removal of Hirohito, which the allies saw as necessary to end Japanese militarism. [See Potsdam Declaration (primary document)]

In a picture dated August 1945, the crew of the B-29 bomber Enola Gay stands before their plane. This plane dropped the bomb on Hiroshima on August 6, 1945. AFP/Getty Images

Japan immediately rejected any surrender that would not leave the emperor on his throne. Less than two weeks later, the Enola Gay dropped an atomic bomb on the city of Hiroshima. "It was to spare the Japanese people from utter destruction that the ultimatum of July 26 was issued at Potsdam," Truman said in a statement following the Hiroshima attack (but before the Nagasaki bombing). "Their leaders promptly rejected that ultimatum. If they do not now accept our terms, they may expect a rain of ruin from the air the likes of which has never been seen on this earth." [See President Truman's Statement Regarding the Bombing of Hiroshima (primary document)]

Following the Hiroshima bombing, there was no sign that the Japanese would surrender. On August 9, the United States dropped a second atomic bomb over the city of Nagasaki, one of southern Japan's largest sea ports. The target had actually been the nearby city of Kokura, but due to cloud cover over that city, the pilots decided to drop the bomb over Nagasaki instead. [See Text of U.S. Leaflet Dropped over Japan Warning of a Second Atomic Bombing (primary document)]

The same day, the Soviets invaded Manchuria, entering the war against Japan. The Soviet Union and Japan had signed a neutrality pact in 1941, but at a meeting with Roosevelt and Churchill near Yalta, Ukraine, in February 1945, Stalin had agreed to join the war against Japan within three months following the end of the war in Europe.

Japan offered its surrender following the Nagasaki bombing, and the official surrender was announced on August 14. While the fate of the emperor had been an obstacle to peace leading up to Japan's surrender, in the end it was agreed that Hirohito would remain on the throne as long as he was subject to the authority of the commander of the Allied occupying force, U.S. General Douglas MacArthur. [See Emperor Hirohito's Radio Broadcast Announcing Japan's Surrender (primary document)]

Although Japan surrendered soon after the Nagasaki bombing, debate still exists over whether it was the bombings or other factors, such as the Soviet entrance into the war, that brought about Japan's surrender. The debate is intensified when moral considerations about the use of atomic weapons enter into it.

The Case for the Atomic Bombing

Supporters portray the Hiroshima and Nagasaki bombings as a necessary means of ending the war with the fewest American lives lost. By shocking and demoralizing the Japanese troops and government through use of the bomb, they argue, the United States brought about a quicker surrender than would have occurred through conventional warfare. "Having found the bomb, we have used it. We have used it to shorten the agony of young Americans," Truman stated after the Hiroshima bombing. Indeed, upon hearing about Hiroshima, 2nd Lt. Paul Fussell, a 21-year-old who had been serving in France at the time and was anticipating being sent to Japan for the final invasion, remarked: "We were going to live. We were going to grow up to adulthood after all." Fussell later became a well-known author.

A scene of the devastation immediately after the United States dropped its first atomic bomb, on Hiroshima on August 6, 1945.

AFP/Getty Images

Supporters at the time estimated that ending the war through the use of the atomic bomb would save thousands--perhaps even hundreds of thousands--of American lives by eliminating the need for a large-scale invasion of the Japanese homeland. Truman's military planners estimated that as many as 50,000 U.S. troops would be killed and more than 100,000 wounded in the first 30 days of such an invasion, with the total number of American deaths possibly surpassing 100,000. Truman later put that estimate at half a million troops, while Churchill said the lives of one million troops had been saved.

But it was not just the lives of U.S. soldiers that were spared, proponents note. They contend that the Japanese civilian death toll would also have been higher if Truman had instead decided to continue with the conventional bombing of Japanese cities and a naval blockade, which was causing starvation. They say that it also brought quicker liberation to people being held by Japan in concentration camps, including hundreds of thousands of Westerners.

Saving lives was not the only reason the United States needed to bring the war to a quick conclusion, some supporters say. They contend that it was important to end the war to prevent the Soviets from expanding their influence in the region. The Soviet Union was developing a growing sphere of influence, and some worried that, through entering the war against Japan and having a say in the partitioning of the defeated territories, the Soviets could gain a large foothold in the region. "I was not willing to hand over to the Russians the fruits of a long and bitter and courageous fight, a fight in which they had not participated," Truman wrote in his diary. Using the atomic bomb ended that threat, and also served as a show of U.S. strength to the Soviet Union. [See Cold War Containment Policy]

Nagasaki also was devastated after the United States dropped an atomic bomb on August 9, 1945. The ruins of the Roman Catholic cathedral of Nagasaki can be seen in the background. National Archives/Newsmakers/Getty Images

Supporters also dispute assertions that Japan was close to surrendering. In fact, they say, the indications were that Japan was preparing to fight to the end. They refer to fierce Japanese resistance at Okinawa just weeks before the bomb was dropped on Hiroshima. They also point to statements by Japanese militarists in power that Japan would resist to the last man. For instance, Kantaro Suzuki, who was appointed premier in 1945, stated that his government intended to "fight to the very end...even if it meant the deaths of one hundred million Japanese."

Furthermore, proponents assert, despite being on the verge of defeat, Japan refused to accept unconditional surrender because that would entail the removal of the emperor from his throne, overturning centuries of tradition. At Potsdam, the Allies had made clear that they would accept no less than unconditional surrender.

Supporters point to intercepted and decoded diplomatic and military communiqués to

show that Japan would not have accepted unconditional surrender. They say that in one such communiqué, Japan's ambassador to the Soviet Union, Naotake Sato, wrote to Soviet foreign affairs commissar Vyacheslav M. Molotov: "The Pacific War is a matter of life and death for Japan, and as a result of America's attitude, we have no choice but to continue the fight.... It has now become clearly impossible for Japan to submit. Japan is fighting for her very existence and must continue to fight."

Some critics of the bombing also point to the communiqués to support their arguments, claiming that they show evidence of peace overtures. But despite some communiqués showing such overtures by civilian leaders, supporters note, any peace agreement had to be approved by the Japanese cabinet, which was filled with militarists who categorically rejected unconditional surrender. Richard Frank, a World War II historian, notes that while the messages showed Japanese officials making peace overtures, "not a single one of these men...possessed actual authority to act for the Japanese government."

Supporters of the use of the atomic bombs also note that the decoded military communiqués showed an increased buildup on Kyushu, the site of the allied invasion planned for November. This buildup, they argue, proves that despite being on the verge of defeat, Japan would continue to put up fierce resistance, which would have resulted in the loss of many American lives. The prospect of heavy resistance at Kyushu also made the invasion option untenable, proponents of the atomic bombing say.

Some people, including some Japanese, have suggested that the bombings helped bring about the end of the war by giving the Japanese a way to surrender unconditionally without losing face. The Japanese government, they argue, could tell the people that Japan simply could not defeat an enemy with nuclear weapons. Hisatsune Sakomizu, Japan's chief cabinet secretary in 1945, called the bombing "a golden opportunity given by heaven for Japan to end the war."

Others point out that, compared with other damage done during the war, the Hiroshima and Nagasaki bombings were not so devastating. They note that 600,000 Germans and 200,000 Japanese had been killed in Allied air raids prior to Hiroshima.

Furthermore, some proponents contend, the United States did not target "civilians" with the bombs, as critics claim. Hiroshima and Nagasaki were military targets, they assert, because of bases and military factories located there. They also note that Japan fought a "total war," in which everyone in Japan was involved in the war effort, whether fighting or working in factories and military facilities. "It seems logical to me that he who supports total war in principle cannot complain of war against civilians," wrote Father John Siemes, a philosophy professor at Tokyo Catholic University, in his personal account of the Hiroshima bombing. [See Minutes of the Second Meeting of the Atomic Bomb Target Committee (primary document)]

Overall, supporters argue, deadly though it was, bombing Hiroshima and Nagasaki was the best possible option. In a 2005 interview with the German magazine Der Spiegel Theodore Van Kirk, navigator on the Enola Gay during the Hiroshima mission, addressed the question of how he felt about his role in the bombing. "I'm not proud of all the deaths it caused, and nobody is," he said. "But how do you win a war without killing people?"

The Case Against the Atomic Bombing

Critics of the Hiroshima and Nagasaki bombings argue that it was barbaric and a crime against humanity to target civilians with such a devastating weapon. They note that 95 percent of the people who were killed in the atomic bombings were civilians. According to Japanese estimates in the wake of the bombings, some 75 percent of those immediately killed died as a result of burns, either from "flash burns" caused by the heat of the blast or from burns from fires sparked by the blast. Many more died later from effects of the radiation, including radiation sickness (also called acute radiation syndrome) and cancer. [See Witnesses' Accounts of the Hiroshima Bombing (primary document)]

A man in Hiroshima (left) shows the photographer the flash burns he received from the dropping of the atomic bomb. Hiroshima, in another view (right), is virtually destroyed, with the exception of an odd building or two. AFP/Getty Images

"My own feeling was that in being the first to use it, we had adopted an ethical standard common to the barbarians of the Dark Ages," Admiral William Leahy, Truman's chief of staff, said. "I was not taught to make war in that fashion, and wars cannot be won by destroying women and children." Some argued that the United States could have achieved the same result by dropping the bomb on less-populated areas, demonstrating its power without the loss of life.

Critics also accuse the United States of having a double standard—its government, they say, would have condemned as immoral the use of an atomic bomb by any adversary. "If the Germans had dropped atomic bombs on cities instead of us, we would have defined the dropping of atomic bombs on cities as a war crime, and we would have sentenced the Germans who were guilty of this crime to death at Nuremberg and hanged them," said Leo Szilard, a scientist who played a major role in the creation of the atomic bomb but who was a vocal critic of using atomic bombs against Japan.

Many critics also claim that the bombings were not necessary. They point out that by 1945, Japan was already militarily devastated and was putting up only token resistance by midyear. "In April we knew they were beginning to try to surrender," wrote historian Gar Alperovitz. "They were already defeated in every sense. We were bombing their cities without any opposition. The Japanese were making airplane gasoline out of acorns. So we knew that they were on their last legs." General Dwight Eisenhower, who succeeded Truman as president in 1953, held a similar view. In an interview with Newsweek in 1963, Eisenhower said, "The Japanese were ready to surrender and it wasn't necessary to hit them with that awful thing."

Opponents also point to a 1946 report by the U.S. Strategic Bombing Survey, requested by President Truman to study the damage done by U.S. air attacks. The report stated that Japan had made the decision to end the war much earlier in the year. The survey concluded:

It cannot be said...that the atomic bomb convinced the leaders who effected the peace of the necessity to surrender. The decision to seek ways and means to terminate the war, influenced in part by the knowledge of the low state of popular morale, had been taken in May 1945 by the Supreme War Guidance Council.

Like supporters of the bombings, critics point to decoded communiqués to bolster their arguments. They note that the decoded messages showed that as early as April and May 1945, Japan was in the process of going through a neutral mediator to make peace overtures, and argue that the United States should have given those efforts a chance to succeed. They also point out that in the months leading up to the bombings, Japan was trying to get the Soviet Union—which, before entering the war against Japan, had maintained a neutral stance with that country—to participate in peace negotiations. Even the Emperor supported peace at any price, critics of the bombing contend. "We have heard enough of this determination of yours to fight to the last

soldiers," Hirohito said at a June 22 meeting of the Supreme War Council. "We wish that you, leaders of Japan, will strive now to study the ways and the means to conclude the war."

And even if Japan was not on the verge of surrendering, critics assert, other means existed to bring an end to the war. Some argued for the planned mass invasion of the Japanese home islands to proceed. Others argued in favor of continuing the naval blockade and disrupting supply lines. "The effective naval blockade would, in the course of time, have starved the Japanese into submission through lack of oil, rice, medicines, and other essential materials," said Admiral. Ernest King, U.S. chief of naval operations.

Some critics argued for continued conventional air raids. They said that the air raids, more than any other military tactic, had devastated Japan. Mark Weber, director of the Institute for Historical Review, points out that on March 9-10, 1945, 300 B-29s bombed Tokyo, killing 100,000 people and burning 16 square miles of the city; further raids by U.S. B-29s later in May obliterated 56 square miles of Tokyo (one half the total area of the city). Former Japanese premier Fumimaro Konoye noted, "Fundamentally, the thing that brought about the determination to make peace was the prolonged bombing by the B-29s."

Others contended that it was the entry of the Soviet Union, which had the largest army in the world, into the war against Japan—not the atomic bombings—that finally convinced Japan that they could not win. "Japanese die-hards...had acknowledged since 1941 that Japan could not fight Russia as well as the United States and Britain," historian Ernest May wrote in a 1995 article in Pacific Historical Review.

Yet other critics argue that Japan would have readily surrendered if the allies had only agreed that the emperor would remain on the throne, which is what was agreed to in the end anyway. Former U.S. president Herbert Hoover (1929-33) suggested to Truman, "I am convinced that if you, as president, will make a shortwave broadcast to the people of Japan—tell them they can have their emperor if they surrender, that it will not mean unconditional surrender except for the militarists—you'll get a peace in Japan —you'll have both wars over."

Other critics were concerned with the ramifications of using an atomic bomb in battle. Szilard warned that dropping the bomb would spark an arms buildup between the United States and the Soviet Union. Szilard said he was concerned "that by demonstrating the bomb and using it in the war against Japan, we might start an atomic arms race between America and Russia which might end with the destruction of both countries."

Finally, some accuse the United States of ulterior motives in dropping the bomb. Some cite revenge for the Pearl Harbor attack, while others claim racism against the Japanese. Yet others say it was done for political reasons: either to justify the $2 billion spent on the project to develop the bomb, or as the only way to obtain Japan's unconditional surrender, because the political cost of accepting anything less was too

high.

Hiroshima Bombing Ushers in The Nuclear Age

Sixty-five years after the bombings of Hiroshima and Nagasaki, the debate over whether the bombings were necessary remains unresolved. But there is little dispute over the wider impact of the use of the atomic bomb: With the bombing of Hiroshima, the United States ushered in the nuclear age.

However, while the use of the bomb helped spark a nuclear arms race between the United States and the Soviet Union, analysts point out that Hiroshima and Nagasaki also served as a lesson about the devastation nuclear weapons can cause, serving as a deterrent to the use of such weapons. Newsweek points out that since the Nagasaki bombing, roughly 525 above-ground nuclear explosions have taken place, and not one was an act of war. "One president after another and one leader of the Soviet Union after another," atomic weapons historian Richard Rhodes has written, "looked at the destructive force of these weapons [after the Hiroshima and Nagasaki bombings] and made a private decision that there is no context in which they could ever be used."

But some warn that the lessons will eventually be forgotten, increasing the nuclear risk as states begin to reverse decades-long efforts toward nuclear disarmament. "I worry that the memory of Hiroshima and Nagasaki is beginning to fade," says Mohamed ElBaradei, the director of the International Atomic Energy Agency. "I worry also about the nuclear arsenal of democratic states, because as long as these weapons exist there is no absolute guarantee against the catastrophic consequences of theft, sabotage, or an accident." However, only time will tell whether the lessons of Hiroshima and Nagasaki will linger or be forgotten in an increasingly nuclear world.

Bibliography

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Donnelly, Thomas. "Bearing the Burden." Bulletin of the Atomic Scientists, July/August 2005, 55.

Frank, Richard. "Why Truman Dropped the Bomb." Weekly Standard, August 8, 2005, 20.

"I'm Not Proud of All the Deaths It Caused." Der Spiegel, August 5, 2005, www.spiegel.de.

Kennedy, David. "Crossing the Moral Threshold." Time, August 1, 2005, 50.

Krieger, David. "Remembering Hiroshima & Nagasaki." WagingPeace.org, August 1, 2003, www.wagingpeace.org.

Kristoff, Nicholas. "Blood on Our Hands?" New York Times, August 5, 2003, A15.

Kross, Peter. "The Decision to Drop the Bomb." World War II, July/August 2005, 40.

"Living Under the Cloud." Time, August 1, 2005, 36.

MacEachin, Douglas. "The Final Myths of the War With Japan: Signals Intelligence, U.S. Invasion Planning, and the A-Bomb Decision." Center for the Study of Intelligence, December 1998, www.odci.gov/csi.

"President Truman Did Not Understand." U.S. News & World Report, August 15, 1960, 68.

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MLA Chicago Manual of StyleCitation Information

Kauffman, Jill. “Atomic Bombing of Japan: Barbaric Tactic or Quick Way to End the War?” Issues & Controversies in American History, Infobase, 1 Oct. 2005, https://icah.infobaselearning.com/icahfullarticle.aspx?ID=107297. Accessed 12 Nov. 2019.

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