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MAXWELL FINLAND March I5, I902-October 25, 1987 BY FREDERICK C. ROBBINS DR. FINLAND, KNOWN TO most people as Max, was a giant in the field! of infectious diseases, although physically he was far from a giant, his height being not much over 5 feet. He was a prodigious worker en c! his bibliography in- cluclec! more than 800 scientific articles en c! a large num- ber of chapters in books, meeting proceedings, en c! various reports. Some of his studies on the natural history en c! patho- genesis of infectious diseases were classics, such as his se- ries of reports on pneumonia. He was a pioneer in the assessment of antibiotics, inclucling their use en c! misuse, in recognizing the significance of antibiotic resistance, en c! in pointing out the importance of hospital infections en c! their control. He was an exemplar of the icleal academic physi- cian, who, in aciclition to conclucting research, was a teacher and a superb physician. This paragon was born in a small town in the Ukraine in 1902. His forebears incluclec! a great-grancifather who was the grant! rabbi of Krakow en c! a grandfather who was can- tor in Zashkov. In spite of this impressive backgrounc! he clic! not seem to have much involvement in formal religion. At the age of four he came with his family to live in Boston. Like so many immigrants, Max's family valucc! education. He gracluatec! from Boston English High, ranker! seconc! in 103

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04 BIOGRAPHICAL MEMOIRS his class, en c! was acceptec! at Harvarc! College with a schol- arship. He thrives! in the exciting environment of Harvarc! of that clay. He hac! such stimulating professors at lames Bryant Conant (chemistry en c! later presiclent), Louis Fiezer (chemistry), Richarc! Cabot (social ethics), Zachariah Chaffee C. ( constitutional law), ant! Winthrop John Vanleuven Osterhout (botany). Max en c! some other students estab- lishec! a club for Hebrew speakers where they heart! reports from Israel. He also taught in a Hebrew school, for which he receiver! some pay. IncleecI, by one means or another he largely supporter! himself throughout his education. In 1922 Max enterer! Harvarc! Meclical School. There he came uncler the influence of Hans Zinsser, chairman of the Department of Microbiology, en c! Milton Rosenau, chair- man of preventive medicine en c! hygiene. Rosenau was an impressive figure en c! Zinsser was an exceptionally dynamic en c! charismatic incliviclual. lames Howarc! Means, chief of medicine at the Massachusetts General Hospital was also influential. After graduation, Max became an intern on the 2nd Medical Service at the Boston City Hospital (BCH). At that time the situation at BCH was almost icleal for some- one interested in academic medicine. The Harvarc! Mecli- cal Unit incluclec! two meclical wards (the 2nc! en c! 4th) en c! the Thornclike Memorial Laboratory. In aciclition, there was the excellent Pathology Unit, heaclec! by Mallory, en c! the South Department, which was the Contagious Disease Hos- pital. In aciclition to Harvard, both Tufts en c! Boston Uni- versities concluctec! teaching units at the hospital. The Harvarc! Unit must have been a heacly environment for a young man. The Thornclike Laboratory en c! the clinical ser- vices were essentially one unit en c! extensive clinical research was being conducted there. Max apparently had planned to go into practice, but as it turned out he found the environ

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M A XW E L L F I N L A N D 105 ment at BCH so highly compatible that he spent almost his entire career there as a member of its Harvarc! Unit. After his internship Max acceptec! the position of pneu- monia resident at BCH, but he also worker! in Rosenau's department, where anti-pneumococcal serum was being pro- clucecI. In 1929 FinIanc! was asker! by Dr. Nye to join his laboratory at the Thornclike. Thus began one of the most remarkable careers in the field! of infectious diseases. The first studies concluctec! by Max en c! his associates clealt with pneumonia. At that time the only treatment for pneumococcal pneumonia was administration of type-spe- cific antiserum. The process of treating patients was cum- bersome, to say the least. A naso-pharyngeal swab was taken en c! placer! in a tube containing culture meclium. After a few hours of incubation when enough bacteria hac! prolif- eratecI, material from the culture was exposer! to type-spe- cific antisera. If there was a match between the antiserum en c! the chemical composition of the polysaccharicle on the surface of the bacterium, the capsule wouic! swell en c! it conic! be seen with an ordinary light microscope (known as the Quellung reaction). If Quellung occurred, the corre- sponcling antiserum (horse or rabbit) was aciministerec! to the patient. The patients usually survives! the infection, but they invariably sufferer! from serum sickness, which conic! be most unpleasant. FinTanc! en c! his fellows clic! a series of studies on the treatment of pneumococcal infection con- cluctec! with meticulous care, a hallmark of FinIancl's re- search throughout. When sulfonamicles became available the infectious disease group at the Thornclike was among the first to concluct systematic clinical studies with the backup proviclec! by the Thornclike laboratories. With the advent of penicillin, again the FinIanc! group clic! many of the funciamental studies of the antibacterial spectrum, pharmacokinetics, en c! to some extent mecha

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06 BIOGRAPHICAL MEMOIRS nism of action. This was repeater! as the various broacI-spec- trum antibiotics were clevelopecI. The studies involves! care- ful clinical observations integratec! with laboratory investi- gations en c! were examples of what the BCH unit macle possible. FinIanc! early recognizec! that bacteria were cleveloping resistance to the antibiotics in general use. He reaTizec! the implications of this en c! that the indiscriminate use of anti- biotics in the hospital en c! in the community was important in promoting the clevelopment of resistance. He recom- menclec! the reservation of certain antibiotics for use only in special circumstances in order to preserve their availabil- ity for emergencies. He also was one of the first to sounc! the alarm about the frequency en c! importance of infec- tions acquirer! in the hospital. Although the contributions just mentioned were impor- tant, they by no means reflect the scope of his interests. In fact, he en c! his collaborators (mainly fellows) explorer! al- most every aspect of infectious diseases that one could men- tion. The infectious diseases division of Thorndike, headed by Finland for most of its existence, was tremendously pro- cluctive. As aireacly mentioned, FinTancl's personal bibliog- raphy inclucles more than 800 scientific papers en c! an acI- clitional 20 to 30 chapters of books en c! contributions to publisher! proceedings of meetings en c! symposia. FinIanc! hac! a great attraction for young physicians who came to work with him. He took a personal interest in each one en c! was careful to see that they were recognizes! for their contributions. Characteristic of him is the history he wrote of the Division of Infectious Diseases. The descrip- tion of each project begins by identifying the fellow or fel- lows involvecI. It is not clear just how many fellows passer! through his division, but it probably exceeclec! 100. The author of this memoir recognized 27 as leaders in the field

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M A XW E L L F I N L A N D 107 throughout this country en c! abroad. It inclucles such names as Wesley Spink, Lowell Ran tz, John Dingle, Charles Rammelkamp, George Gee Jackson, Lewis Thomas, Calvin Kunin, Theodore Eickhoff, en c! Edward! Kass, to name a few. FinIanc! spent most of his career at BCH in the Harvarc! Meclical Unit. His home base was the Thornclike Memorial Laboratory, a key element in the Harvarc! Unit. Before re tirement in 1968 he hac! become its director en c! the clirec- tor of the Harvarc! Unit. The Thornclike was an extraorcli- nary organization. It was heaclec! by such luminaries as Francis Peabody, George Minot, William Castle, en c! Max FinIancI. On the staff were such well-known figures as Chester Keefer (later to move to Boston University), Soma Weiss, Charles Davidson, Joseph Wearn, en c! Thomas Hale Ham. Although the Thorndike was not very impressive physically, this re- markable group of people was immensely productive, en c! it influencec! a large belly of young men en c! women who collectively hac! a profounc! impact on meclical care, re- search, en c! teaching for several generations. The famous statement by Francis Peabody in his paper "The Care of the Patient," "The secret of the care of the patient is in caring for the patient," governec! the behavior of the Harvarc! Unit. Although the close relationship between the Thornclike en c! the Harvarc! clinical services was exploitee! to the benefit of clinical investigation, the patients were always treater! with respect, even though they were almost exclusively from the poorer segment of society. When I was a fourth-year Harvarc! student on the Harvarc! service, George Minot was our visi- tant. Of course, I regarclec! him with awe. However, I was most impressed when on rounds we were examining a woman who was in for pneumonia or some acute illness. She worker! as a waitress, was single, en c! hac! many personal problems. Minot sat clown by her becisicle en c! spent 10 to 15 minutes discussing her personal clifficulties with evident concern

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08 BIOGRAPHICAL MEMOIRS for this aspect of her life. To him she was not just a case of pneumonia. This macle quite an impact on the students en c! seemec! to exemplify Dr. Peabocly's dictum in action. In 1973 the Thornclike Memorial Laboratory severer! its relationship with BCH en c! mover! to the Beth Israel Hospi- tal, a major Harvarc! affiliate locater! about one block from the Basic Sciences quadrangle. Indeed, Harvard severed all relationships with BCH when the governing belly of BCH cleciclec! to affiliate with a single meclical school en c! chose Boston University. This decision was the result of a number of factors, inclucling the shrinking patient population at the hospital en c! the close proximity of the Boston Univer- sity Hospital to BCH. In any case, it enclec! a 50-year rela- tionship between Harvarc! en c! the hospital, which hac! been remarkably productive en c! one in which Max FinIanc! hac! played such a key role. As mentionec! before, Max was a small man physically, but this never seemec! to affect his behavior. From the time Max enterer! Harvarc! College he was associates! with Harvarc! en c! its meclical school until his cleath in 1987. He was loyal to the institution en c! clisplayoc! this in many ways inclucling sizeable contributions from his personal resources. He was also influential in stimulating others to contribute, en c! it is estimatec! that he was responsible for contributions of ap- proximately $6 million. In recognition of his many contri- butions to Harvarc! en c! to the health of the public, the Max Finland professorship in clinical pharmacology was funded at Harvarc! Meclical School. The other institutions that commanclec! his loyalty were the BCH, the Harvarc! Meclical Unit, en c! in particular the Thorndike Laboratory. Max never married, but he had a devoted extended fam- ily in his many friends and the large number of young people for whom he served as mentor, teacher, and friend. He was a prodigious worker, but he always had time to discuss a

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M A XW E L L F I N L A N D 109 problem with colleagues, inclucling fellows or even house officers en c! students. He enjoyoc! the symphony, usually taking along a frienc! or fellow. He also entertained at the Athens Restaurant or a favorite Chinese restaurant (Ye Hong Gucy's). My wife and I had the pleasure of joining him a couple of times at the Chinese restaurant, en c! they were convivial occasions, with Max the perfect host. In 1968 Max retiree! en c! became the Minot professor emeritus en c! shortly thereafter he mover! his office to the Channing Laboratory heaclec! by Edward! Kass. He contin- ucc! to publish en c! to supervise fellows. He was also given an appointment at the Veterans Administration Hospital. Thus, Max continues! to clisplay one of his main attributes: a remarkable capacity for hare! work. One of the prodigious tasks he undertook in his retirement was the ecliting of a three-volume history of the Harvarc! Meclical Unit at Bos- ton City Hospital. The history inclucles brief statements by many of the young physicians who spent some time in the unit en c! who represent a large proportion of the impor- tant contributors to academic medicine for over half a cen tury. FinTanc! receiver! many honors. He was a member of the National Academy of Sciences en c! recipient of the Kober Mecial of the Association of American Physicians, the Bristol Awarc! of the Infectious Diseases Society of America, the Chapin Awarc! of the City of Providence, the Philips Awarc! of the American College of Physicians, the Oscar B. Hunter Awarc! of the American Society of Clinical Pharmacology en c! Therapeutics, en c! the Sheen Awarc! of the American Meclical Association. He receiver! honorary degrees from Western Reserve en c! Thomas Jefferson Universities. In 1982 FinIanc! was awarclec! a cloctor of science (honoris cause) clegre e from Harvarc! University, some thing Harvarc! clo es not often clo for its own faculty. The citation reacts: "The

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0 BIOGRAPHICAL MEMOIRS University hails a clistinguishec! en c! loyal son, who for sixty years as physician, teacher, en c! scholar has given wisclom, energy, en c! substance to the advancement of clinical mecli- cine. " As a fitting enc! to this memoir I quote from the presen- tation of FinIancl's goof! frienc! en c! associate Charles Davidson when he presented the Kober Mecial: "We honor tociay a man who, with a friencIly smile en c! a quiet en c! moclest manner, has achiever! great distinction not only because of his extraordinary contributions to American medicine but also because of his beneficial influence on so many pa- tients, students, colleagues, en c! friends." REFERENCES Davidson, C. S. 1978. Presentation of the George M. Kober Medal for 1978 to Maxwell Finland. Trans. Assoc. Am. Phys. 91:51-62. Finland, M. 1982-83. The Harvard Medical Unit at Boston City Hospital, Harvard Medical School vols. I, II, and III. Distributed by the Uni- versity Press of Virginia for the Francis A. Countway Library of Medicine. Peabody, F. W. 1927. The care of the patient. 7. Am. Med. Assoc. 88:877-82.

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M A XW E L L F I N L A N D SELECTED BIBLIOGRAPHY 1930 111 Serum treatment of lobar pneumonia. N. Engl. /. Med. 202:1244-47. 1931 With W. D. Sutliff. Type 1 lobar pneumonia treated with concen- trated pneumococci antibody (Felton). 7. Am. Med. Assoc. 96:1465. With W. D. Sutliff. Specific cutaneous reaction and circulatory anti- bodies in course of lobar pneumonia. No serum. 7. Exp. Med. 54:637. With W. D. Sutliff. Specific cutaneous reaction and circulatory anti- bodies in course of lobar pneumonia. Serum. 7. Exp. Med. 54:653. 1933 With W. D. Sutliff. Immunity reaction of human subjects to strains of pneumococci other than 1, 2, and 3. 7. Exp. Med. 57:95. 1935 With J. M. Ruegsegger. Immunization of human subjects with spe- cific carbohydrates of Type 3 and related Type 8 pneumococcus. /. Clin. Invest. 14:829-32. 1936 With R. C. Tilghman. Bacteriological and immunologic studies in families with pneumococcal infections; development of type spe- cific antibodies in healthy contact carriers. 7. Clin. Invest. 15:501. 1939 Specific treatment of pneumococci pneumonia analysis of results of serum therapy and chemotherapy at BCH from July 1938 through June 1939. Ann. Intern. Med. 13:1567-93. 1942 Spread of pneumococcal and streptococcal infections in hospital wards and in families. Aerobiology, pp. 212-22.

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2 BIOGRAPHICAL MEMOIRS 1944 With M. Meads, H. W. Harris, and B. A. Samper. Treatment of meningococcal meningitis with penicillin. N. Engl. I. Med. 231:509- 17. 1945 Cold agglutinins; cold iso hemogglatins in primary atypical pneu- monia of unknown etiology with rate on occurrence of hemolytic anemia in these cases. 7. Clin. Invest. 24:458-73. 1946 With C. S. Davidson and S. M. Levenson. Chemotherapy and con- trol of infection among victims of Coconut Grove disaster. Surg. Gynec. Obst. 82:151-73. With R. Murray, L. Kilham, and C. Wilcox. Development of strepto- mycin resistance of gram negative bacilli in vitro and during treatment. Proc. Soc. Exp. Biol. Med. 63:470-74. 1947 Use of penicillin in infection other than bacterial endocarditis. Adv. Intern. Med. 2:350. 1968 With F. F. Barrett and J. I. Casey. Infections and antibiotic use among patients at Boston City Hospital, February 1967. N. Engl. J. Med. 278 (1) :5-9. 1970 With F. F. Barrett, J. I. Casey, and C. Wilcox. Bacteriophage types and antibiotic susceptibility of Staphylococcus aureus. Boston City Hospital, 1967. Arch. Intern. Med. 125~5~:867-73. 1973 Excursions into epidemiology: Selected studies during the past four decades at Boston City Hospital. 7. Infect. Dis. 128 ~ 1 ~ :76-124. 1974 With J. E. J. McGowan. Infection and antibiotic usage at Boston City Hospital: Changes in prevalence during the decade 1964-1973. J. Infect. Dis. 1 2 9 ~ 4 ): 42 1 -2 8 .

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M A XW E L L F I N L A N D 1975 113 With J. E. J. McGowan and M. W. Barnes. Bacteremia at Boston City Hospital: Occurrence and mortality during 12 selected years (1935- 1972), with special reference to hospital-acquired cases. 7. Infect. Dis. 132 (3) :316-35. Relationships of antibiotics in animal feeds and salmonellosis in animals and man. 7. Anim. Sci. 40 ~ 6~: 1222-40. 1976 With C. Garner, C. Wilcox, and L. D. Sabath. Susceptibility of "en- terobacteria" to aminoglycoside antibiotics: comparisons with tet- racyclines, polymyxins, chloramphenicol, and spectinomycin. 7. Infect. Dis. 134(suppl.~:57-74. 1977 With M. W. Barnes. Changes in occurrence of capsular serotypes of Streptococcus pneumonias at Boston City Hospital during selected years between 1935 and 1974. 7. Clin. Microbiol. 5~2~:154-66. 1979 Pneumonia and pneumococcal infections, with special reference to pneumococcal pneumonia. The 1979 J. Burns Amberson lecture. Am. Rev. Respir. Dis. 120 ~ 3 ~ :481 -502. Emergence of antibiotic resistance in hospitals, 1935-1975. Rev. In- fect. Dis. 1 (1) :4-22. 1984 With E. Strauss and O. L. Peterson. Landmark article June 14, 1941: Sulfadiazine. Therapeutic evaluation and toxic effects on four hundred and forty-six patients. By Maxwell Finland, Elias Strauss, and Osler L. Peterson. 7. Am. Med. Assoc. 251 ~ 11 ~ :1467-74. With M. A. Barry and D. E. Craven. Serotypes of Streptococcus pneumonias isolated from blood cultures at Boston City Hospital between 1979 and 1982. 7. Infect. Dis. 149~3~:449-52.