Maxwell Finland: A Remembrance

On 15–16 March 2002, friends, colleagues, and fellows of Maxwell Finland gather in Boston to celebrate the 100th anniversary of his birth. The occasion marks the dedication of the Maxwell Finland Conference Room at the Countway Medical Library, Harvard Medical School, Boston, and a scientific program highlighting the contemporary importance of his contributions. His career in infectious diseases spanned more than 50 years, from his appointment as the Pneumonia Resident at Boston City Hospital in 1928 until he left the hospital in 1983 and died in October 1987. A plaque in the Maxwell Finland Laboratory for Infectious Diseases at the Boston Medical Center summarizes his accomplishments: He exemplified the finest qualities of physician, teacher and investigator. His association of more than 50 years with the Boston City Hospital began in 1926 and culminated in his appointment as Director of the Harvard Medical Services and the Thorndike Memorial Laboratory. He was author or co-author of more than 800 scientific papers including pioneering studies of the pneumococcus and diagnosis and management of pneumonias, clinical pharmacology of antimicrobial agents and hospital epidemiology. He was mentor and counselor to more than 100 fellows in infectious diseases who continue his tradition of scientific excellence. Maxwell Finland was born on 15 March 1902 in a small village in the Russian pale, near Kiev. The family was relatively uneducated but was well-versed in biblical and Talmudic lore and took pride in their great-grandfather, who had been the chief rabbi of Krakow [1]. In 1906, the family escaped the difficulties of life in the ghettos of Eastern Europe and migrated to the United States, where the family found a home in the ghetto of the West End in Boston. As was true for many of his contemporaries, education was the ticket of passage out of the ghetto. He graduated from Boston English High School and was admitted to Harvard College. He graduated cum laude from Harvard in 1922 and from Harvard Medical School in 1926. His passage through Harvard was made possible by newsboy scholarships and by earning funds through teaching Hebrew. One can only imagine the intensity of scholarship, perseverance, and sheer labor, given the restrictions of the time. Max spent the years of 1926–1927 as an Assistant Resident Physician at the Boston Sanatorium caring for patients with tuberculosis. In 1927, he was appointed to the house staff at the Boston City Hospital and came under the influence of such teachers and colleagues as Francis Weld Peabody, George Minot, William Castle, Chester Keefer, Soma Weiss, Frank Mallory, and many others. His career in infectious diseases began when he accepted an offer to become Resident Physician for Pneumonia Patients in 1928. This resident was responsible for the continuous care of patients who had pneumonia, with their many complications, as well as the initiation and conduct of clinical studies of diagnosis and management, including investigation of the newly developed antipneumococcal sera. Research assistants were not available to the Resident Physician; he was his own technician. Over the years, Max remained devoted to the Boston City Hospital and its patients. He maintained an apartment at the hospital and was always available to the house officer or fellow for advice on professional or personal matters. He rose in the academic ranks and was appointed George Richards Minot Professor of Medicine at the Harvard Medical School, Director of the II and IV Medical Services at the Boston City Hospital, and Director of the Thorndike Memorial Laboratory in 1963. His commitment to the Harvard Medical Unit at the Boston City Hospital is reflected in his 903-page history of the Thorndike Memorial Laboratory and the Harvard Medical Services [2]. During the late 1920s and early 1930s, pneumococcal pneumonia accounted for one-half of the deaths at the Boston City Hospital. The type specificity of the Pneumococcus species had been identified and the potential value of specific antisera was being investigated. Dr. Finland's first paper on pneumococcal disease was published in the New England Journal of Medicine in 1930: “The Serum Treatment of Lobar Pneumonia” [3]. During the next 10 years, he would publish approximately 100 papers, most of which focused on pneumococcal infections and their diagnosis and management. Dr. Finland had a repository of type-specific sera for diagnosis and therapy. When a house officer had a patient with a pneumococcal isolate recovered from sputum, blood, or other body fluid, he would seek out Dr. Finland to have the organism typed and to obtain serum to administer to the patient. Physicians who trained during the 1930s have described the sequence of events necessary to use serum therapy: you went to the hospital laboratory to get the isolate; if the house officer was not at the City Hospital, he got on the trolley and traveled to the Thorndike Memorial Laboratory, where Dr. Finland was always available; he would type the organism and hand you a bottle of type-specific serum; then, it was back on the trolley to your hospital; finally, you administered the serum to the patient. Whereas the mortality rate for untreated pneumococcal bacteremia was almost 90%, type-specific serum therapy resulted in survival of more than one-half of the patients [4]. In 1933, Domagk [5] announced the discovery of Prontosil, the diazonium derivative of sulfanilamide. Finland studied the action of these new compounds when combined with antisera. The first publication appeared in 1938 on the treatment of pneumococcal meningitis with sulfanilamide alone or in various combinations with specific antipneumococcal sera [6]. His manuscripts included case histories that were crammed with details about the clinical course, the various diagnostic tests, and the duration and amount of drug or serum administered (figure 1). Although the amount of detail was often overwhelming for the medical student (particularly when presented as a lantern slide during a lecture), Finland's figures provided valuable data about the clinical course and the results of therapy. Max was quick to point out the adverse events associated with prolonged use of the sulfonamides, including agranulocytosis and the development of sulfonamide-resistant strains [7]. One of Finland's figures summarizing the clinical course of pneumococcus type IV meningitis with bacteremia complicating otitis media [5]. The late 1940s and the 1950s were marked by evaluation of each of the new antimicrobial agents. The first studies were of the tetracyclines; then, the more active penicillins and, after the synthesis of the penicillin nucleus in mid-1950s, the array of new penicillins, such as methicillin, oxacillin, nafcillin and ampicillin; and, in the 1960s, the first generation of cephalosporins. Each drug was studied in meticulous detail, including its in vitro activity and pharmacokinetics. Fellows and house staff participated in studies of absorption and excretion of each product: blood samples were obtained at 30 min and 1, 2, 4, and 8 h; urine samples obtained over a 24-h period were used to determine the proportion of drug excreted [8]. Figures representing serum concentrations and urinary excretion in normal subjects appeared in numerous articles (figure 2). The “normal subjects” who provided blood and urine for the pharmacokinetic studies were us—his fellows and the residents on the II and IV Harvard Medical Services at the Boston City Hospital ($2 per specimen of blood and $5 for 24-h urine specimens, but payment was made only if the sample was complete). The in vitro activity of the drug was presented as a curve of the cumulative percentage of strains at increasing MICs [9], a format that became known as a “Finlandogram” because of its unique and clear presentation (figure 3). Finland's figures showing the results of his studies of serum concentrations of ampicillin [8]. "Finlandogram" showing the in vitro activity of gentamicin against various organisms [9] During a period of 40 years that began in 1933, young physicians sought to spend postgraduate training in infectious diseases under the supervision of Dr. Finland. Harry F. Dowling was the first of more than 100 Finland Fellows. Each was devoted to Dr. Finland not only because of his professional skills but because he took a personal interest in the well-being and academic career of the fellow. Max was a bachelor, so the fellows were his family. The fellows looked at Dr. Finland as his or her professional father. In turn, the fellows shared a common bond as brothers and sisters in this extended family. There were social occasions when Dr. Finland reveled in sharing the occasion with his fellows and members of the Thorndike Memorial Laboratory and the Harvard Medical Units at the Boston City Hospital. He took delight in preparing brandy alexanders for the Thorndike Christmas party (figure 4) and giving holiday gifts to the members of his extended family. The Thorndike Christmas party with Dr. Finland pouring his homemade brew of brandy alexander. Courtesy of the Harvard Medical Library in the Francis A. Countway Library of Medicine. Max was a superb clinician and enjoyed patient care and bed side teaching (figure 5). Making rounds on patients on the II and IV Medical services with Dr. Finland was always a treat—subtle signs were identified, seen by those who gathered around the bedside, and never forgotten—for example, the rose spots of typhoid fever, the Janeway lesions of endocarditis, the desquamation around the nail beds that were an indicator of prior scarlet fever, the discrete erythematous macules that signalled the onset of meningococcemia). Max did not tolerate the ill-informed or lazy house-officer, and he had a temper that was apparent to any who failed to meet his standard of medical care. Ward rounds on Peabody 1 at Boston City Hospital, 1964. Left to right, Frank E. Speizer, Herman A. Godwin, Robert A. Buccino, M. Finland, Theodore Stack (Harvard Medical School class of 1964), John J. Tudor (Harvard Medical School class of 1964), and a patient with acute rheumatic fever. Courtesy of the Harvard Medical Library in the Francis A. Countway Library of Medicine. By the time the Infectious Diseases Society of America was formed in 1962, the most important member of the organizing committee, Maxwell Finland, was elected its first president. He would continue to play an important part in the fledgling society, and he would receive its Bristol Award for lifetime achievement and have an annual lectureship named after him by the society. Each year, the Massachusetts Medical Society awards a Maxwell Finland Medal for achievement in research by a fellow at each of the 4 medical schools in the Commonwealth, and the National Foundation of Infectious Diseases has an annual Maxwell Finland Award for Life Time Scientific Achievement. He received numerous awards and honors, but none of these, including other honorary degrees, meant as much to him as the award of the honorary doctorate from his alma mater in 1977 (figure 6). All who knew Dr. Finland delight in the group picture of the honorees, including Max sitting next to Mother Theresa. Honorary degree recipients at Harvard University Commencement in June 1977. Seated, Composer Virgil Thomson, Boston College President J. Donald Monan, missionary Mother Teresa, Dr. Maxwell Finland, Sir Peter Medawar. Standing, John Charles Polanyi, Francis Hardon Burr, Harvard University President Derek Bok, Tennessee Williams, Shandong University President Wu Fu-heng, flutist Doriot Antony Dwyer, and former United Nations Ambassador Donald F. McHenry. Courtesy of the Harvard Medical Library in the Francis A. Countway Library of Medicine. We celebrate the life of this extraordinary physician. His career bridged the decades from the 1920s, when little was available to stem the course of infectious diseases, to the 1980s, when most major infectious diseases had been controlled. For those of us fortunate enough to have known Maxwell Finland, this is an occasion of fond remembrance of a person and time that shaped our lives and academic careers.