In the early 20th century, the future of hospital-based clinical pathology practice was uncertain and this situation led to the formation of the American Society for Clinical Pathologists in 1922. Philip Hillkowitz, MD, and Ward Burdick, MD, were its cofounders. No biography of Hillkowitz exists.
To explore the life, beliefs, and accomplishments of Philip Hillkowitz.
Available primary and secondary historical sources were reviewed.
Hillkowitz, the son of a Russian rabbi, immigrated to America as an 11-year-old child in 1885. He later attended medical school in Cincinnati, Ohio, and then moved to Colorado, where he began his clinical practice, which transitioned into a clinical pathology practice. In Denver, he met Charles Spivak, MD, another Jewish immigrant and together they established the Jewish Consumptives' Relief Society, an ethnically sensitive tuberculosis sanatorium that flourished in the first half of the 20th century because of its national fundraising network. In 1921, Hillkowitz and Burdick, also a Denver-based pathologist, successively organized the pathologists in Denver, followed by the state of Colorado. Early the next year, they formed the American Society for Clinical Pathologists (ASCP). Working with the American College of Surgeons, the ASCP put hospital-based practice of clinical pathology on solid footing in the 1920s. Hillkowitz then established and oversaw the ASCP Board of Registry of Medical Technologists.
Philip Hillkowitz changed the directions of clinical pathology and tuberculosis treatment in 20th century America, while simultaneously serving as a successful ethnic power broker within both the American Jewish and Eastern European immigrant communities.
Philip Hillkowitz, MD, (Figure 1) and his friend and colleague Ward Burdick, MD,1 2 pathologists from Denver, Colorado, were the cofounders of the American Society for Clinical Pathologists (ASCP), an organization established in 1922 to raise standards of practice in clinical pathology.2–5 This fledgling organization faced a huge task, as this was essentially a new field of medical practice. The term clinical pathology had a different meaning in the 1920s than it does now.6 Throughout the 1920s and in the early 1930s, it was a new specialty encompassing the practices of both anatomic pathology (ie, autopsy pathology and the rapidly emerging field of surgical pathology—cytopathology was in its infancy in the 1920s and outside of the scope of practice of most “clinical pathologists” 7) and most of what is today called clinical pathology (ie, clinical chemistry, hematology, hematopathology, medical microbiology—blood banking was also in its infancy in the 1920s and outside of the scope of practice of most “clinical pathologists” 8). Before the early 20th century, pathology was primarily an academic subject taught in medical schools. While pathology was critical subject matter for physicians and surgeons throughout the 19th century, one could not make a living practicing as a pathologist—except for the few pathologists who were professors of pathology teaching the subject to medical students. Nevertheless, physicians needed to have a basic understanding of pathophysiology in order to practice medicine because in the years before laboratory tests and diagnostic imaging, the internist's primary mode of diagnosis was data derived from history and physical examination placed squarely in the context of the practitioner's understanding of pathology.9 Additionally, those practicing surgery needed to have a basic understanding of gross surgical pathology. In the 19th century, pathology was essentially an autopsy-based theoretical subject that supported the salaries of professors in medical schools. Pathologists were not normally involved in the delivery of patient care. Ironically, even though autopsies were the staple of the late-19th-century pathologist, clinicians wanting to know why their patients died often performed their own autopsies to maximize opportunities for clinicopathologic correlation.9–11
Philip Hillkowitz, MD. Credit: JCRS Bulletin. February 1948;18(2). Courtesy of the JCRS Collection, Beck Archives, University of Denver.
Philip Hillkowitz, MD. Credit: JCRS Bulletin. February 1948;18(2). Courtesy of the JCRS Collection, Beck Archives, University of Denver.
In the last decade of the 19th century, the few diagnostic laboratory tests available to clinicians were simple enough that they could be performed on the ward by themselves or by residents.12–14 However, by the early 20th century, laboratory testing had evolved so quickly that complicated tests such as the Wasserman complement fixation test for syphilis, bacteriologic culture, among others, required additional expertise.15–17 This, combined with the fact that the results of testing performed in general practitioner's offices and in hospital wards by internists or residents were not standardized and could be highly suspect, created a potential niche for specialists to provide laboratory testing. Two competitive models arose in the first 2 decades of the 20th century: commercial laboratories, often run by technologists, versus hospital-based laboratories run by clinical pathologists.6 The former, because of high test volumes and lower personnel costs, often offered rapid service and cheap prices, while the latter, although sometimes less efficient, offered more personalized service, ease of consultation related to the appropriateness of tests and the interpretation of results, and, most importantly, the ability to perform in-hospital intraoperative frozen section diagnosis to actually guide the surgeon's hand in real-time during operations.18,19 By 1920, those practicing the new field of hospital-based clinical pathology believed that they were losing the battle with commercial laboratories and would soon be extinct.6 At the same time, there were vicious battles as to whether the laboratory tests they performed were a medical consultation or simply a commodity and, if the latter, whether testing should be done by unsupervised or minimally supervised technicians. It was these battle fronts, along with the genuine desire to improve the quality of practice of clinical pathology, that propelled Hillkowitz and Burdick to organize the clinical pathologists first in Denver, followed by those in the entire state of Colorado, and, within a year, in the United States of America.
Other simultaneous events facilitated their cause, most notably the hospital-based clinical pathology service model. Physicians and surgeons who had served in the American Expeditionary Forces during World War I (WWI), many of whom had never worked with pathologists before the war, returned in the thousands having grown to rely upon the high-quality pathology and laboratory services they had encountered overseas. Louis B. Wilson, MD, the director of pathology at the Mayo Clinic (Rochester, Minnesota),20 had established a world-class laboratory service in Europe during the war.21 Many physicians and surgeons now expected the same in civilian life. In the civilian world, tissues removed at operation in the early 20th century were generally thrown in the garbage can rather than examined by a pathologist.6,18 While some commercial laboratories and most state public health laboratories did offer some histologic services, these tended to have very long turnaround times for results.6,22 The ASCP leadership rapidly recognized that routine histopathologic examination of all surgical specimens, availability of intraoperative frozen sections,6 new prognostication tools such as tumor grading,23 and autopsies for quality assurance were all highly desirable to surgeons and that surgeons could become their strongest allies to establish their hospital-based practice. At the same time, the American College of Surgeons (ACS), an elite specialty guild of well-trained surgeons formed in 1913 with a mission to improve surgical practice in North America, was highly motivated to set a minimum standard for hospitals. The ACS had expressed an interest in access to improved laboratory services but did not know exactly what that really meant; however, the leadership of the ASCP quickly created a symbiotic relationship with the ACS, which essentially solidified hospital-based positions for the ASCP membership.24 While the ASCP had started out totally at odds with the American Medical Association (AMA), its leadership soon recognized that the AMA's Council on Medical Education and Hospitals was another natural ally.24 It was Hillkowitz and Burdick, along with their ASCP leadership colleagues, who analyzed the complex and constantly changing puzzle, put all the pieces together, and established their new specialty, hospital-based clinical pathology, on firm footing in less than a decade.24 Before 1930, the commercial laboratory model was on its way to extinction.6
One of us (J.R.W.) has previously written a biographical sketch of Ward Burdick1 ; this current article will attempt to accomplish the same for Hillkowitz, but with only minimal overlap with the Burdick article. It is not possible almost a hundred years later to break down the precise contributions of each to the rapid organization of clinical pathologists in America, but it is possible to make general observations. Hillkowitz, who became the first president of the ASCP in 1922, was a natural leader; at the time the ASCP was formed, he was also simultaneously president of the Denver County Medical Society and the Jewish Consumptives' Relief Society (JCRS), a Denver-based national tuberculosis (TB) sanatorium treatment center that earned a respected national reputation, and featured offices in both New York and Denver, as well as numerous Ladies Auxiliaries in many large American cities to support its massive fund-raising campaigns (see below). Written records clearly demonstrate that Hillkowitz was the mouthpiece for the ASCP, as he immediately led its first important battle with the powerful AMA related to the appropriateness of its policy permitting commercial laboratory advertisements in its journal.6 Burdick, the secretary of the ASCP until his death, seems to have handled the organization's logistics and, in conjunction with Hillkowitz, backroom planning; his importance to the cause is forever documented by the fact that the ASCP named its most prestigious award after Ward Burdick.1 Hillkowitz and Burdick proved to be a powerful duo who quickly organized clinical pathologists across America.
DENVER, COLORADO IN THE LATE 19TH AND EARLY 20TH CENTURY
Tuberculosis, consumption, or the “white plague,” as it was also known, was the leading cause of death in America, and in the late 19th and early 20th century, owing to its sunny dry climate and high altitude, Colorado drew tens of thousands of TB victims to the state to “chase the cure.” Before the advent of antibiotic treatment, moving to Colorado was considered by many physicians to be the best treatment for pulmonary TB, and the state soon earned an international reputation as “the World's Sanatorium.” 25 Burdick came for this reason, as he had contracted TB while working as a pathologist in St Louis, Missouri.1 Hillkowitz moved to Denver after graduating from medical school in Cincinnati, Ohio, because its favorable climate had helped his father's asthma symptoms.
PHILIP HILLKOWITZ
Little has been written about the life of the pathologist Philip Hillkowitz, except what has been published in brief obituaries and biographical catalogues.26–29 However, he was also the president of the JCRS of Denver and, by reviewing extensive archival materials related to JCRS,30 a much more complete picture of Hillkowitz's life can be constructed. Moreover, one can gain further insights into how his Eastern European background, his religious beliefs, and his new found love of modern American culture influenced his career as well as his role in the history of American pathology.
Philip Hillkowitz was born in Salant, in northwestern Lithuania on August 30, 1873. His parents were Rabbi Elias (Elya) Hillkowitz (born July 1836 in Rutwan, Kovno, Russia) and Rebecca (Riva) Hillkowitz (Hindel) (born June 1837); they were married in Lithuania. Elias served as a rabbi in Pickeln, Kovno.31 Elias immigrated to New York City in 1881 and the remainder of the Hillkowitz family followed in 1885 when Philip was 11 years old. They soon relocated to Cincinnati. According to Philip Hillkowitz:
My father came to Cincinnati at the call of Kalman Hirschman, the owner of a wholesale notion and dry goods store, who wanted him as a rabbi and a tutor for his children. . . . (He) founded his own congregation . . . in a loft. . . . It was the period of infancy for orthodox Judaism and as an index of its poverty in worldly goods my father received . . . $3.00 a week and mother Rebekah had to slave for boarders.32
Rabbi Hillkowitz moved to Denver because of his asthma in either 1890 or 1892–1893 (sources differ). Although Philip recalled that in Denver his father “served without pay as rabbi, frequently settling quarrels among local orthodox spiritual leaders of congregations . . . ,” 32 other sources indicate that he was respected as the “dean of the city's Orthodox rabbinate,” owing to his erudition, and the fact that he was educated in the leading Jewish yeshivas (advanced schools of Jewish learning) of the time in Lithuania, having received his ordination from the well-known, venerated head of the Russian rabbinate.33
Philip's older brother, Dr William Hillkowitz, and older married sister, Rose Hillkowitz Holzberg, remained in Cincinnati, but his other siblings moved to Denver with their father. An older brother Solomon (born March 1870) became the manager of the Denver Vegetable Growers Association but later moved to San Diego, California. His younger sister, Anna (born April 1879), still an adolescent, eventually obtained the qualifications to work as a librarian before marrying a New York City dentist, Abe Bresler, and later moving to San Diego. Nothing is known about Philip's other sister, Ella (born August 1875), except that she moved to New York when Anna married and died there in December 1921.
Philip stayed behind and graduated from University of Cincinnati (Cincinnati, Ohio) in 1894 (BSc) and Medical College of Ohio (Cincinnati) in 1897. He then moved to Denver, became licensed in Colorado, and established a practice there in 1897. During the next decade, he became more and more consumed with laboratory work and his administrative roles at the JCRS (see below). However, although Philip became a highly accomplished and Americanized Jewish immigrant, his Jewish roots resonated deeply with him throughout his career. He was especially sensitive to the plight of his impoverished and ill fellow Jewish Russian immigrants. It is likely that his older brother, Dr William Hillkowitz, served as a role model for Philip in this regard. In addition to a successful medical practice in Cincinnati, from its inception in 1891, William donated his medical services virtually free of charge to the Society for the Relief of the Jewish Sick Poor.34
In 1910, Dr Hillkowitz discontinued general practice in order to fully devote his time to JCRS and clinical pathology. According to census data,35 he had his laboratory office in the Metropolitan Building and had partners—Dr Helen Craig (1883–1965) from 1917–192136 and Dr Harry Gauss (1888–1969) from 1923–1924.37,38 Dr Hillkowitz served as director of laboratories at JCRS, Beth Israel Hospital (Denver, Colorado),39 Mercy Hospital of Denver (Denver, Colorado),40 and St. Anthony's Hospital (Denver, Colorado)41 as well as St. Joseph's Hospital in Alliance, Nebraska.42 The exact years for each of these hospital appointments are unclear, but he was well known in Denver for many years as he conspicuously made his rounds from hospital to hospital. According to a newspaper article in the Rocky Mountain News on May 3, 1959: “Dr. Philip Hillkowitz was a cyclist. It was a familiar sight to see the distinguished physician pedaling through the streets on his rounds – with a massive medical book propped on his handlebars, studying as he went and oblivious to traffic.” 43 He also served as the Colorado State and City of Denver chemist as well as associate professor of chemistry at the University of Denver (Denver, Colorado) starting in 1935.29
Philip Hillkowitz married Minnie Freshman (born 1877 in Russia) of Denver on June 5, 1914. A family friend, Rabbi C. E. H. Kauvar, spiritual leader of the Beth Medrosh Hagodol traditional synagogue, officiated. It was apparently Minnie's second marriage, but she had no children from her first marriage.35 The Hillkowitzs likely had 1 child, as his obituaries mention a daughter, Mrs R. B. Armstrong of Folsom, California.26 Nothing is known of Hillkowitz's daughter. From the surname, we may speculate that his daughter's spouse was not Jewish, and the family may, therefore, have been estranged.
Dr Hillkowitz served as a captain in the Medical Corp in WWI; however, it is not clear whether he went overseas. When he enlisted, the Board of the JCRS hosted an “eatless banquet in his honor” (Figure 2). The idea was to celebrate and honor his enlistment, but with austerity. He was sent to the Rockefeller Institute (New York, NY) for a period of “intensive training in research work” on July 28, 1918, and then was sent to Washington, DC, almost certainly to the Army Medical Museum. One source noted that wherever he would be posted in Europe after that, he would not need a translator, as he was a linguist with fluency in 14 languages.44,45 However, it seems likely that he may never have made it to Europe as the war ended a few months after he enlisted. Regardless, he was back in his post as president of the JCRS for the 15th Annual Convention of the JCRS in St Louis in May 1919. Mr David Gross, first vice president, reportedly did an excellent job in his absence; the JCRS avoided the great influenza pandemic though rapid implementation of well-conceived public health measures.46
Captain Hillkowitz at the Jewish Consumptives' Relief Society (JCRS) Board's “eatless banquet,” Wednesday July 24, 1918. Dr Hillkowitz is in an Army Captain's uniform seated at the head of the table. Also present are many JCRS committee chairs, including Dr O. M. Shere, chairman of the Medical Advisory Board (second from the far right), and Dr Charles Spivak, secretary (seated immediately to the left of Dr Hillkowitz). Credit: Beck Archives, University of Denver.
Captain Hillkowitz at the Jewish Consumptives' Relief Society (JCRS) Board's “eatless banquet,” Wednesday July 24, 1918. Dr Hillkowitz is in an Army Captain's uniform seated at the head of the table. Also present are many JCRS committee chairs, including Dr O. M. Shere, chairman of the Medical Advisory Board (second from the far right), and Dr Charles Spivak, secretary (seated immediately to the left of Dr Hillkowitz). Credit: Beck Archives, University of Denver.
Early in his career, he was a professor of bacteriology and pathology at Gross Medical College (1898–1900) in Denver, Colorado; following a merger, he was professor of pathology at the Denver and Gross College of Medicine (1900–1906),29 which merged with University of Colorado School of Medicine (Boulder, Colorado) in 1910.47,48 His curriculum vita no longer exists but his publication record after 1916 was pieced together “old style” by searching by hand the AMA's Quarterly Cumulative Index to Current Medical Literature from 1916 (its first volume) and Quarterly Cumulative Index Medicus until his obituary appeared; in an attempt to rule out publications before 1916, the Index-Catalogue of the Library of the Surgeon General's Office: United States Army, series 2 to 4, was also searched. Dr Hillkowitz published at least 19 peer-reviewed papers in the medical literature. Six of these were very brief articles in the Colorado Medical Journal. Three were written during the time that the ASCP and the ACS were working together to standardize hospitals, related to the role of clinical pathology in standardized hospitals.49–51 Four late in his career were related to standardization of training of laboratory technologists. Most of the remainder related to a few original observations concerning anatomic pathology. A list of his publications has been placed in his file at the Beck Archives at the University of Denver. In his role as president of the JCRS, he published his annual Presidents' Report in either their newsletter, The Sanatorium, or later, the JCRS Bulletin. For many years, he also published an annual Jewish New Year greeting in the Bulletin.
As noted earlier, in 1922, he was a cofounder and elected the first president of the ASCP. He was simultaneously the president of the Denver County Medical Society. He served as the chair of the ASCP Board of Registry of Medical Technologists for 12 years starting in 1928 (see below).
In addition to being the son of a prominent rabbi and a Hebrew scholar, Hillkowitz was a locally renowned linguist with knowledge of 14 languages, was knowledgeable about many cultures, and was often called upon as a translator. He also had a wicked sense of humor. According to the Rocky Mountain News:
When Dr. Spivak (see below) died, he bequeathed his body to the University of Colorado Medical School for anatomical studies. Some years later the skeleton was donated to further the resources of a new medical school in Israel. A visitor from another city who had not learned of Dr. Spivak's death inquired of Dr. Hillkowitz one day about his friend's activities. “Oh, haven't you heard?” Dr. Hillkowitz replied. “My good friend Dr. Spivak is now teaching anatomy in Israel.” 43
In September 1938, Hillkowitz became seriously ill and had 2 delicate operations to remove blood clots from his brain. He recovered completely and lived to continue to lead the JCRS for another 10 years and collected many acclamations and awards; he was particularly loved by labor unions and New Yorkers (Figure 3).
Philip Hillkowitz with New York City Mayor La Guardia. Credit: JCRS Bulletin. May 1943;13(5). Courtesy of the JCRS Collection, Beck Archives, University of Denver.
Philip Hillkowitz with New York City Mayor La Guardia. Credit: JCRS Bulletin. May 1943;13(5). Courtesy of the JCRS Collection, Beck Archives, University of Denver.
THE JEWISH CONSUMPTIVES' RELIEF SOCIETY
One of Philip Hillkowitz's most fruitful professional and personal relationships was with his fellow Russian Jewish immigrant colleague, Charles Spivak, MD. Like Hillkowitz, Spivak grew up in a traditional Jewish home in Russia in the 19th century. Spivak, however, who was born in 1861, became a radical revolutionary socialist in his youth and fled Russia when he was in his early twenties to avoid being apprehended by the secret police. He sailed to the United States in 1882, and after several years working in various jobs as a laborer, factory hand, and aspiring farmer until he perfected his English, he settled in Philadelphia and graduated with a medical degree with honors from the Jefferson Medical College (Philadelphia, Pennsylvania). He migrated to Denver in 1896 with his family because of his wife's ill health. As prominent medical men who shared a similar background, the two soon crossed paths and became close friends. Spivak turned his early political revolutionary sentiments to a radicalism of a different sort—the care of impoverished Jewish immigrant patients in all stages of TB. Both Hillkowitz and Spivak understood the psychological aspects of the disease, as well as the medical side, and fought to found a TB sanatorium that would provide a Jewish atmosphere that would make the patients feel at home and comfortable. As a result, Philip and his friend Charles Spivak helped establish the JCRS in 1903–1904 in concert with a group of poor immigrant Jewish working men.25
In the early years of the JCRS, it met considerable opposition from the National Jewish Hospital (NJH) of Denver, Colorado, which had opened its doors in 1899.52 While both relied primarily on the contemporary accepted treatment of robust exposure to fresh air, enforced rest, and meals that emphasized nutritious foods such as milk and eggs, as well as providing free treatment to patients with TB regardless of their religious beliefs (although in reality, most patients at both institutions were of Eastern European Jewish origin), the 2 institutions otherwise stood in stark contrast. The NJH had been organized by wealthy, liberal Reform German Jews while the JCRS had been organized by less affluent, more traditional Eastern European Jews, which was consistent with the background of both Spivak and Hillkowitz. The NJH had specifically sought out a few wealthy German-American Jewish donors, while the JCRS had been established mostly by poor Eastern European Jews. As noted by Spivak: “with the exception of a few large donations, whose number can be counted on the fingers of one hand, all of our income came, as in the previous years, in small donations from poor people, and from various Jewish organizations.” 53(p27) Some of their medical philosophies differed as well. The NJH, along with most sanatoria of the time, which were influenced by progressive-era emphasis on efficient business practices, accepted only patients with TB early in the course of the disease. However, the JCRS accepted all patients with TB in all stages of the disease, even severe cases, reasoning that those were the ones who needed the most assistance. Both Hillkowitz and Spivak maintained that this was in line with the traditional Jewish concepts of tdedakah (commonly translated as charity but literally meaning justice) and mercy. The JCRS approach had been sharply criticized and projected to have dire consequences, which Hillkowitz addressed in his Presidential Address of 1906: “all of those portentous predictions of dire calamities – of flooding Colorado with consumptives, of lowering prices of real estate, of increasing racial prejudice, of quarantine against tuberculosis – all of these have vanished as mist before Colorado sunshine.” 53(p11) By 1906, the 2 Jewish sanatoria, while still highly competitive, had evolved from a bitter rivalry to a more friendly competition, and the 2 Jewish sanatoriums inspired Lutherans and Scandinavians to establish their own relio-ethnic–based sanatoriums in the Queen City. While care at the JCRS was open to all, most patients were Russian Jews and so the JCRS was especially sensitive to traditional Jewish customs, served kosher ethnic food from the onset (NJH did not open a kosher kitchen until 1923), and celebrated the Jewish Sabbath and holidays, such as Passover, faithfully. The NJH approach was much more “westernized.” The 2 institutions even looked different. The JCRS quickly evolved into a pastoral campus with gardens and a dairy farm, while the NJH looked like a typical modern American hospital, although it later established a farm in the Denver suburbs to supply the patients with fresh dairy products as well. The JCRS also became a haven for socialist political views, as it was populated by Russian and Eastern European Jews, many with beliefs that were not entirely compatible with their new homeland. Moreover, the JCRS honored the Yiddish language, which many German Jews viewed as an inferior version of the German language, and indeed, Spivak was the coauthor in 1911 of a celebrated Yiddish-English dictionary. Still, Hillkowitz and Spivak were both highly appreciative of their American citizenship and worked to ease the JCRS patients into American culture, probably in a manner more sensitive than that exhibited at NJH. American holidays such as the Fourth of July were also celebrated enthusiastically.54
The Hillkowitz family was instrumental in establishing the JCRS. Philip was its founding president and then was reelected president for 43 consecutive years. In this role, he served on the board and many committees. He was also the primary pathologist and bacteriologist for JCRS, and, while he was still working as a general practitioner, he was a consulting physician. Rabbi Elias Hillkowitz was one of its 3 incorporators and suggested the organization's motto from the Talmud: “He who saves one life is considered as if he had preserved the world.” Rabbi Hillkowitz died on January 21, 1906.55 Philip's concern for the well-being of his Jewish brethren was highly influenced by his father's example. Philip's sister, Anna, taking a leave of absence from the Denver Public Library, traveled as the JCRS's first field secretary (ie, traveling fund raiser) in 1906 and 190756; her success became a prototype for the organization, which later employed dozens of field secretaries. Anna also served on JCRS committees in its early years. Philip's brother, Dr William Hillkowitz, referred patients with TB from Cincinnati, and early in its history, William penned an editorial in a leading Jewish newspaper of the day, The American Israelite, defending the work of the JCRS against its early critics.57 Both Philip and William purchased bonds to support the construction of new buildings at JCRS.
The Hillkowitz children kept many traditional values but, perhaps linked with the passing of their father, appear to have become less Orthodox and more Americanized. As noted by one of us, Anna “did personally observe many Jewish traditions and customs. However, it is doubtful that she followed strict Orthodox religious practices. It is highly unlikely . . . that an Orthodox Jewish woman at the turn of the century would have traveled across the country on her own, particularly speaking before mixed audiences.” 56(p280) As was the case with his good friend Dr Spivak, throughout Philip's career, he seems to have been motivated by his desire to become fully American and modern, but simultaneously find ways to retain his Jewish Eastern European cultural tradition. He accomplished the former through his work both as a state-of-the-art clinical pathologist and by organizing clinical pathologists across America; he accomplished both the former and the latter through his work at the JCRS and his support, along with Spivak, of the Zionist cause. By reading his annual presidential reports, one can feel his pride that his organization was growing, thriving, and constantly modernizing even though the patients, mostly Jews of Eastern European or Russian origin, could feel religiously, culturally, and gastronomically at home. Both Hillkowitz and Spivak, while insisting that the JCRS exhibit a more overt Jewish atmosphere in contrast to the German-run NJH, were still focused at the same time on acculturating, modernizing, and Americanizing their Eastern European Jewish immigrant brethren. In addition, Spivak and Hillkowitz were likely involved in somewhat of a power struggle with German Jewish leaders, like those at NJH, and clearly wanted to demonstrate that Russian Jews like themselves could head a medically modern, up-to-date hospital. Perhaps nowhere did modernism, cultural sensitivity, and orthodoxy battle more than over the concept of autopsy.
JEWISH BELIEFS AND THE AUTOPSY
Drs Spivak and Hillkowitz and most or all of the JCRS Board believed that autopsies should be performed at JCRS when patients died, but this was in most circumstances considered to be against rabbinic law. In 1914, Spivak published an article entitled “Post Mortem Examinations Among Jews—An Historical Sketch and a Plea to Jewish Physicians” in the New York Journal of Medicine.58 Records are unclear whether any autopsies were performed at JCRS before 1918 but 5 were performed that year.59 Although legal consent was obtained from the next of kin, this was a controversial change in policy in the context of such a traditional environment.
In 1924, Maxim Pollak, MD, resident physician at the JCRS, wrote an article entitled “The Jewish Law Permits Autopsies,” which Spivak reputedly read at a board meeting before its publication in The Sanatorium, which also included the board's discussion of the article. Pollak noted that “there is great controversy between Rabbis who are strictly against autopsies, on the one hand, and the Jewish physicians and enlightened laity, on the other side.” 60(p99) He also correctly noted that, in the 1920s:
The hospitals which stand on a higher medical plane and possess a greater and more satisfactory medical service for their patients are those where the proportion of autopsies is the highest. As a fact, the medical standard of a hospital can be measured by the relative number of autopsies performed therein.60(p99)
Pollak explained that rabbinic laws and decisions codified in the Schulchan Aruch by Rabbi Joseph Caro in the 16th century are accepted by Jews around the world. Pollak noted:
In cases of difference of opinion, or in cases not foreseen in the code mentioned above, the decisions of the Rabbis of their day and generation is sought. It is therefore natural to expect that a thing which is permitted by one Rabbi, may be prohibited by another Rabbi. Rabbis, like doctors, differ. A diligent search through the Bible, Talmud and Schulchan Aruch did not reveal any law prohibiting autopsies.60(p99)
He then made a few historical observations about possible early Jewish autopsies, which seem highly questionable to us, as he had confused autopsies with anatomic dissection. However, he then quickly focuses on the widely cited interpretation of Rabbi Ezekiel Landau of Prague (1713–1793). Landau, who had been approached by rabbis in London who disagreed on the permissibility of autopsies, decided as follows:
When it concerns the saving of a human life, there can be no question of the permissibility of an autopsy, because the saving of a human life supercedes all commandments of the Torah, except three: shedding of the blood, lust, and idolatry. In our case, however, there is no sick man present who needs to be cured immediately. For the sake of a similar case that might happen in the future, we are not permitted to transgress an injunction of the Torah. For if we should minimize the importance of autopsies, God forbid, they would be practiced on all the dead indiscriminately.60(p99–100)
In other words, Landau opposed autopsies except if the knowledge gained could immediately save a life. This essentially precluded performing autopsies on deceased Jewish patients, except under exceedingly unusual circumstances. This interpretation was clearly at odds with the standard of care that JCRS physicians and leadership had decided to provide. The JCRS, by seeking consent from relatives of deceased patients and performing autopsies, had apparently ruffled some feathers and was feeling some heat—but at the same time was unwilling to back down:
The agitation of the Rabbis against autopsies which commenced at a time when the physicians at the Jewish Consumptive Relief Society in their eagerness to search for causes and cure of tuberculosis performed autopsies on those who showed obscure and puzzling symptoms during life, is still continuing. If it keeps on any longer it is liable not only to retard the progress of Jewish physicians but should they succeed in stopping autopsies, the Jewish physicians soon will fall behind their Gentile colleagues in their knowledge of the art of healing. We are not going too far, when we state, that this will not only mean the decay of a Jewish profession, but it will also have a very bad effect on the Jewish people in general. The main argument against autopsies is based upon the decision of Rabbi Ezekiel Landau of Prague. But since this authority permits the performance of autopsies when a sick man is present who needs to be cured immediately, surely in our hospitals there are always present many people afflicted with the same disease. There is no autopsy from which one would not gain some knowledge, and which could not be applied immediately for the benefit of other patients. Furthermore, the knowledge thus gained is utilized immediately by publishing the findings in the medical periodicals. As soon as some discovery or observation is made, be it ever so slight, it is broadcasted through the channels of the medical literature throughout the world. Some sufferer at the antipodes is getting the benefit of the newly gained knowledge. I am glad to state that some of the Rabbis in the United States hold views in regard to this question which are more in accord with the Talmudic spirit and with modern conception.60(p100)
Throughout this article, the author pits modernity against what he considered unscientific Old World customs. He also pointed out that the Board and staff of the JCRS had been pushing “propaganda of education among Jews of the United States on behalf of autopsies” since 1915.60(p101) The author concluded by invoking the JCRS motto “he who saves one life is considered as if he preserved the whole world” and then stating that “millions of lives have been saved by the knowledge obtained through autopsies, and therefore for a purely Jewish religious stand point the performance of autopsies among Jews should be encouraged.” 60(p101)
The JCRS Board then discussed the article after Spivak had presented it and a motion supporting autopsies was proposed, discussed, and unanimously passed. Dr Spivak raised another point supporting both anatomic dissection and autopsies:
We are going to build a university in Palestine, the very first department will be a medical department. . . . How will you study anatomy? It is time we should understand the situation. Our first thought should be that if by cutting up my body I can help my son or grandchild to recover, we should say so in our wills. My will contains it, and Dr. Hillkowitz's will contains it, and when our dear co-worker, Dr. Shere died, we did not hesitate to perform the autopsy on him, and his dearest friend performed the autopsy, and we all stood by. We felt bad, and we felt sad, but we felt that Dr. Shere's death should not go unrewarded, that we should get, even after his death, some benefit for humanity.60(p101)
JCRS autopsy statistics are sporadic but, for the years these are available, highly revealing. The earliest year for which any data were found was 1918, when 5 autopsies were performed. For the 15 years between 1924 and 1948 for which full data are available, there were 142 autopsies and 434 deaths, or an average autopsy rate of 32.7% (the annual range was 8% to 58.1%).
While similar autopsy-to-death ratio data are not available for the NJH, it is highly unlikely that, even with their more secular approach to running a hospital, they were able to achieve similar autopsy rates, especially considering that at the time the AMA instituted a requirement for a minimum autopsy rate of 15% for all hospitals wishing to be approved to train interns and residents, AMA projections indicated that at least 55% of the presumably better hospitals that were currently training interns would not meet the new standard in 1929.24 The autopsy-to-death ratios at the JCRS had met the new 15% requirement a decade earlier, which is an astounding achievement. Perhaps the arguments that Spivak and Hillkowitz both made were so compelling within the JCRS community that this resulted in a degree of local acceptance. The fact that both Spivak and Hillkowitz had indicated in their wills that they wanted autopsies on themselves and that their chief of surgery, Dr Shere, underwent an autopsy when he died probably helped. However, it is interesting to note that even when the controversial issue of autopsy was discussed, it was against the backdrop of traditional Jewish law. In other words, Spivak and Hillkowitz did not attempt to simply justify autopsy as a desirable modern medical practice, but rather to persuade their traditional Jewish audience that given the various historical Talmudic references on the subject, it might be interpreted as not being in defiance of Jewish legal dictates.
While a significant number of highly educated Orthodox Jewish scientists and legal ethicists still opine today that autopsy is prohibited by Jewish law in most cases, it appears that the respect that the mostly poor Eastern European clientele of the JCRS had for the beliefs of their trusted brethren, Spivak and Hillkowitz, seems to have prevailed. While it is also possible that, since the JCRS had a mixed patient population, the rate for Gentiles was higher and this helped increase the average rate, this could not in itself have accounted for such high rates because few of the patients were Gentiles. Regardless of why, it must have given Spivak and Hillkowitz some real bragging rights and reinforced their beliefs that their culturally sensitive institution was at the cutting edge of modern medical care.
OTHER EVIDENCE THAT JCRS LABORATORY SERVICES WERE FIRST RATE AND MODERN
The clinical laboratory at the JCRS was established in 1908. In several of the Medical Advisory Committee Annual Reports, laboratory space and infrastructure improvements are mentioned. In many of the annual reports, data about the numbers and types of laboratory tests performed are available. By 1924, the laboratory had implemented a frozen section service and was collecting informative postmortem and operating room specimens for its new medical museum.63 The individual test menu expanded most years.
Another interesting observation along the same lines is that the JCRS met the ACS Minimum Standards for Hospitals from the very beginning and they mention this in their Bulletin from time to time—for instance, in the same issue in which they announced the passing of Hillkowitz, they posted a brief advertisement about their ACS certified laboratory,64 which was entirely fitting, as Hillkowitz was responsible for the partnership linking his ASCP and the ACS.6 The fact that the JCRS was always approved is totally amazing, as some important upper echelon academic hospitals could not meet these standards in the early years of the ACS Standards.24 Figure 4 shows one of their advertisements in the JCRS Bulletin showing this success. In another issue of the Bulletin, an accreditation letter from the ACS was published verbatim indicating that we have no suggestions to improve your laboratory.65
Jewish Consumptives' Relief Society (JCRS) meets American College of Surgeons minimum standards for hospitals again. Credit: JCRS Bulletin. February 1948;18(2). Courtesy of the JCRS Collection, Beck Archives, University of Denver.
Jewish Consumptives' Relief Society (JCRS) meets American College of Surgeons minimum standards for hospitals again. Credit: JCRS Bulletin. February 1948;18(2). Courtesy of the JCRS Collection, Beck Archives, University of Denver.
Perhaps, because their president was a clinical pathologist, the JCRS repeatedly demonstrated both that they were proud of their clinical laboratory and that it was “world class” 66–68 (Figure 5).
Registered medical technologists working in one of the state-of-the-art laboratories in the Rude Medical Building in 1939. Credit: JCRS Bulletin. December 1939;9(5). Courtesy of the JCRS Collection, Beck Archives, University of Denver.
Registered medical technologists working in one of the state-of-the-art laboratories in the Rude Medical Building in 1939. Credit: JCRS Bulletin. December 1939;9(5). Courtesy of the JCRS Collection, Beck Archives, University of Denver.
HILLKOWITZ AND THE ASCP BOARD OF REGISTRY OF MEDICAL TECHNOLOGISTS
As soon as the ASCP was formed in 1922, Hillkowitz immediately did battle with the AMA Advisory Advertising Committee and the AMA Board of Trustees. The AMA maintained that laboratory tests were commodities, that anyone with appropriate training could provide these services, and that, as commodities, it was appropriate to advertise prices. Hillkowitz strenuously maintained that laboratory tests were not commodities, that clinical laboratories provided consultative medical services, and that the AMA code of ethics prevented physicians from advertising and, especially, advertisements that included prices.6 Hillkowitz explained that the entire Society opposed commercial laboratories run by technicians, as well as “ghost” commercial laboratories that were nominally overseen by prominent professors of pathology but who in actuality had only “lent” their names and reputations, for a fee, to help technician-run commercial laboratories obtain market share—even though they themselves were not actually involved in providing any of the laboratory services.6 Hillkowitz was pointedly asked by a Board member whether or not he and other ASCP members performed every test themselves or whether ASCP members employed technicians in their own laboratories and, if so, how was that different? Hillkowitz explained that all of the work in their laboratories was directly supervised by them.6 Clearly, the matter of only employing qualified technicians was critical to the credibility of their new profession and yet there was no real way to confirm the knowledge and skill set of any given technician applying for a job.
As the society was forming, other entities had already expressed interest in regulating technicians, and some state medical societies were even considering licensing technicians, as there was a shortage of trained clinical pathologists. Hillkowitz and other ASCP leaders opposed this and favored national certification without licensing.69 The ASCP needed a workable solution acceptable to diverse parties and so they created a committee to explore options. The negotiated solution was complicated with many parties involved.70 The Journal of the American Medical Association explained it as follows:
The Registry for Clinical Laboratory Technicians.—In 1928 the American Society of Clinical Pathologists established a registry to pass on the qualifications of laboratory technicians and to approve schools for training these workers. Soon this Registry received the recognition of the American Medical Association, the American College of Surgeons, the American Hospital Association, the Catholic Hospital Association, and other scientific and medical organizations. The Council on Medical Education and Hospitals was authorized to formulate standards and approve schools which meet its requirements. After a thorough test, conducted by clinical pathologists, successful applicants for a certificate were designated Medical Technologists (M.T.), a title which connoted a holder of a certificate of competence from the Registry, nationally recognized in the medical and hospital spheres.71(p1269)
Ward Burdick was to have chaired the registry but died unexpectedly on March 24, 1928.72 Hillkowitz replaced him and credited Burdick with having “set up the machinery in his office to conduct the Registry” and stated that he had simply relocated the registry to his own office.73(p222) Hillkowitz ran the Board of Registry for 12 years from his 234 Metropolitan Building office in Denver. His personal secretary, Mrs Anna Ruth Scott, served as the registrar, and as the workload increased, an additional secretary was added to the staff. According to Hillkowitz:
The early history of the Registry was not all smooth sailing. Many obstacles had to be overcome before reaching quiet waters. Some of the clinical pathologists in the first years, who did all their own laboratory work looked with suspicion on the training proposal as creating potential competitors. This outlook may seem somewhat absurd in the present age but when considered in the historical setting it was not entirely illogical.73(p223)
Another problem that continued in the early years of the registry related to continued attempts by some states to license technologists. This time it was opposed by the combined forces of the ASCP, the Board of Registry, the ACS, the American Hospital Association, and the AMA Council on Medical Education and Hospitals.74
Hillkowitz credited Kano Ikeda, MD, the secretary of Board of Registry, for much of the progress and it is clear that Ikeda was an excellent organizer and administrator.75–77 Hillkowitz eventually became known as the “granddaddy of medical technologists” and said “I am proud of this title as expressing affection to one who has taken a deep interest in the progress and welfare of this useful profession from its very inception.” 73(p221)
Just before Hillkowitz retired from the Board of Registry, he had to deal with “pernicious activities of a New Jersey organization which presumes to issue certificates of qualification to laboratory technicians in opposition to our own Registry.” 78(p310) The AMA became involved and its Journal published the following text:
Within the past six months one C.A. Bartholomew of Red Bank, New Jersey, who has never himself been registered, began to circularize the medical laboratory technicians of New England asking them for a fee of $5 to join the “American Medical Technologists” and offering to bestow the title of M.T. by virtue of a charter from the State of New Jersey. As far as we know, this movement is not supported or authorized by any scientific body. The promoters seem, moreover, to have undertaken the task of passing on the competence of training schools for medical technologists. In this they seem to be abetted by the proprietors of some commercial schools which have not themselves been approved by the Council on Medical Education and Hospitals and the Registry. This would seem to be the old technic of having one soiled hand wash the other. Graduates from these unapproved schools who are ineligible for the Registry's examination seem to be welcomed into the “American Medical Technologists.” . . . Complaints have come to both the Council and the Registry against the efforts of this unauthorized and irresponsible body to undermine the scientific and ethical standards that have been set up for the practice of this important vocation by the American Medical Association and the American Society of Clinical Pathologists. Certainly physicians everywhere will do their utmost to inform young men and women who contemplate a career in medical technology of the hazard that lies in participation in such courses or organizations.71(p1269–1270)
Dr Hillkowitz retired later in 1940 because of illness and was replaced by Lall G. Montgomery, MD, of Ball Memorial Hospital in Muncie, Indiana. Hillkowitz's second secretary moved to Muncie to help with the transition.72
PHILIP HILLKOWITZ'S DEATH AND LEGACY
Dr Hillkowitz died at Mercy Hospital at the age of 74 years of a cerebral hemorrhage on Friday January 30, 1948; he had suffered a stroke while presiding at a contentious JCRS Board meeting the night before. During his funeral, a eulogy noted this, stating that “so our dear good Dr. Hillkowitz died in the midst of the work he loved best, the work of saving lives of the poor, the sick and the unfortunate.” 79 The Medical Society of the City and County of Denver added some other observations after listing his many accomplishments:
This is a record of which any doctor could be proud, but Dr. Hillkowitz was not a proud man. He was one of nature's noblemen. Notwithstanding his great erudition he was kindly, modest, unassuming, charming, and friendly to everybody. He greeted the office boy and the scrub woman with the same geniality as he would the governor of the state or a justice of the supreme court. He loved all mankind and mankind loved him.79
While his will stated that he wanted to have an autopsy when he died, we can find no evidence as to whether this happened or not. His body was cremated, which would have also contradicted traditional Jewish law. The New York Times devoted half a column to his obituary. He was survived by his wife, Minnie, his daughter, Mrs R. B. Armstrong of Folsom, California, and his sister, Mrs Anna Bresler of San Diego, California.
The Jewish Intermountain News obit quotes:
Dr. Hillkowitz' name was always linked with the Jewish Consumptives Relief Society, from its humble beginnings of tents and wooden structures in 1904 to its present stage of “City of Hope.” With Dr. C.D. Spivak, he presented a new approach to charitable endeavor, treating the patient as a welcome guest, instead of a charity case. He proved to the world the definite need for a sanatorium to care for tuberculosis sufferers regardless of the stage of the disease. . . .
It was this faith that his father gave him that prompted Dr. Hillkowitz to overcome all obstacles in the building of a great institution. He, above all, was responsible for the keeping of all Orthodox tenets at the JCRS, where religious laws are strictly observed, altho (sic) the institution is non-sectarian. He believed in the mental well-being as well as physical care of the patients. This belief brought about the facilities to provide for the patient's outside interests, to make life as a shut in more bearable and prepare them for the time they would again be well enough to make their own way. Now called “Occupational Therapy,” this method is recognized all over the world as an important part of any case. The JCRS is considered a landmark of man's humanity to his fellow sufferers, and many who have never seen the institution give their time and efforts for it all over America. This spirit Dr. Hillkowitz transmitted wherever he went. It was contagious to all who knew him.27
During Hillkowitz's lifetime, his lowly JCRS tent city had evolved into an 148-acre “City of Hope” with 34 buildings, its own town (Spivak, Colorado) on the outskirts of Denver with its own post office, and fund-raising offices in Denver and New York City; during the height of its impressive run, it published glossy commemorative “coffee table” books with pages of advertising for elite New York City establishments, and the New York Giants football team hosted a fund-raiser game for the JCRS every season.80,81 However, Hillkowitz also lived long enough to see the beginning of the end of the white plague, which had been his lifelong dream. With the discovery of antibiotics effective in the treatment of TB before his death, TB would soon come under control, and so the JCRS was repurposed shortly after his death into a cancer treatment facility. In 1954, the former TB sanatorium changed its name to the American Medical Center (AMC) and at about the same time, sold part of its land along West Colfax Avenue and this was turned into a shopping plaza. In 1985 the AMC became a cancer research center and eventually merged with the University of Colorado Health Sciences Center in Aurora, Colorado. In 2002, the Rocky Mountain College of Art + Design (RMCAD; Denver, Colorado) purchased its remaining campus and buildings.82,83 The remaining JCRS infrastructure has now been transformed into RMCAD and, since there was no longer any frontage on Colfax, is now located at 1600 Pierce Street in the Denver suburb of Lakewood. As for the friendly rivalry between JCRS and NJH that had existed during the decades that both were specializing in treating patients with TB, perhaps the NJH was the ultimate winner. While it also transformed itself once the scourge of the white plague had mostly subsided, it continues to thrive as National Jewish Health, an internationally respected academic research and patient treatment center specializing in pulmonary, cardiac, allergic, and other immune diseases.52
The JCRS organization that Hillkowitz and Spivak established had become a powerhouse because of its miraculous ability to fundraise, mostly through the efforts of its myriad of Ladies Auxiliaries, in major cities across the country. It is ironic that about a quarter of a century after Hillkowitz and Burdick established the ASCP and shortly after Hillkowitz's death, the ASCP established its own Ladies Auxiliary in 1948 with Minnie Hillkowitz as its first president.5 While the ASCP Ladies Auxiliary did not have a similar transformative effect and no longer exists, his ASCP has grown and, almost 95 years later, is positioning pathologists and laboratory professionals “for success by providing . . . valuable educational resources and professional development tools including cutting-edge publications, continuing medical education, professional certification, networking opportunities, and representation in Washington. . . . ” 84 Philip Hillkowitz left a robust legacy. In addition to his pivotal contributions to American pathology, Hillkowitz, like his close friend Dr Spivak, also became a successful ethnic power broker within the American Jewish community. Both realized early on that members of diverse religious and ethnic groups often heal better when the medical environment pays respect to their cultural traditions, an outlook that still resonates today.
We thank Thyria Wilson, MLIS, JD, Aaron Davis, MLIS, and Karen Butler-Clary, MLIS, at the Beck Archives, University of Denver; the Interlibrary loan services of the University of Calgary; Charlotte Monroe and Thomas Kryton, BFA, of Calgary Lab Services; and Kristin Rodgers, Collections Curator of The Ohio State University Medical Heritage Center.