"For me, transplantation transcended my career as a surgeon because it permitted me to be a physician, a surgeon, a researcher, and a scientist. And one of the things that was so important in the early days was this whole group of people around the world that were doing this work became a kind of family. And for years our relationships became so close and so intense that in many ways I looked at transplantation almost as my institution as opposed to your total allegiance to a hospital or medical school or a university."
Anthony Monaco, MD, a founding member of the ASTS, served as the 12th ASTS President in 1985-86. A distinguished surgeon and basic science research enthusiast, Dr. Monaco has led several clinical transplant teams in the Northeast including those at the Beth Israel Deaconess Medical Center and the Rhode Island Hospital Kidney Transplant Center. Dr. Monaco is the distinguished Peter Medawar Professor of Transplantation Surgery at Harvard Medical School, and has served as President of the International Transplantation Society, the Massachusetts Chapter of the American College of Surgeons, and the New England Organ Bank. During his ASTS Presidency, Dr. Monaco emphasized ethical guidelines for organ donation and transplantation, transplant surgical education, and expansion of organ donation and transplantation.
Anthony Monaco: Okay, my name is Tony Monaco. I work at Harvard Medical School.
Goran Klintmalm: You have been in this from the beginning, but tell me how did you get involved?
Anthony Monaco: Well I went to the Harvard Medical School in 1952. In 1955, Joe Murray at the Brigham Hospital did the first successful transplant. It’s certainly electrified the entire medical community, certainly it was the rage at our medical school and from then on in, I was clearly interested in transplantation. I then went to Mass General to train in surgery at GH and the transplant program. But when I finished training in 1963, a new professor took over at the MGH, so he wanted to start the program and he offered and gave me a job as his assistant and working in the transplant laboratory there. He started a program in kidney transplants of closely living donors and he had a very intense laboratory effort. He got interested in the development of anti-lymphocyte serum. This was almost surreptitious the way we stumbled on working on that problem. He wanted to use antibodies to interrupt graft-versus-host reactions and we expected to use allogenic antibodies made in, from a member of the same species. But I think without thinking by immunized lymphocytes in rabbits, this gave a very potent heterologous serum and it was extremely immunosuppressant. I have been ashamed to say I wasn’t even aware that Woodruff had done a similar experiment a year before. But I think we used adjuvant-based serum which were much, much more immunologically potent. Once we hit upon this, there wasn’t anything we could not do that did not work.
We developed the experimental serum to prolong allografts, skin allografts, and skin xenografts. We developed a rabbit that was anti-serum to dog lymphocytes that prolonged solid organ grafts. And we made an anti-human serum which we had the audacity to test in our living kidney donor patients. The wives, spouses of these donors, were normal people and they volunteered to be tested with this serum and we showed that it could obliterate late sensitivity reactions and prolong skin grafts.
Goran Klintmalm: Tell me how that process took place between the time that you thought that you should do this in humans. Tell us about all of the review boards and discussions or actually what did you in fact to and how did you go ahead and take it from the laboratory to inject it in the patient?
Anthony Monaco: Well that’s a very good point because to my recollection, we did not bring it before a review committee. We followed what we though was honest, good practice but I do not remember ever bringing it before a review board.
Goran Klintmalm: Did you ask the FDA for approval?
Anthony Monaco: Absolutely not and that’s something I might talk about later on, but I think this was one of the big differences in how we operate today. But I think it was the ability to do these things without a great deal of hassle that permitted us to make such incredible progress. Then around this time we found Starzl then Judd and Jerry also got interested in anti-human and anti-canine serum and also were able to show its effects. This was the most incredible experimental design that I can ever visualize because we could do something that would work and then by word-of-mouth it would literally spread all over the world very, very quickly.
Goran Klintmalm: Where did you keep those rabbit?
Anthony Monaco: We had a great laboratory right in the hospital. We had a small animal laboratory almost contiguous with our offices and we had a dog lab in relation to the cardiac laboratory.
Goran Klintmalm: So you just took…bled the rabbit, prepared the sera and went up to the floor with it?
Anthony Monaco: Right.
Goran Klintmalm: Could you repeat that, repeat what you actually did?
Anthony Monaco: Well we would utilize our mouse protocol for immunization using dog lymphocytes in rabbits. We used our regimen incorporated protocol and we immunized the animals in all four footpads. And then a month…Then six weeks later, we would infuse them with intravenous lymphocytes and then we would bleed them. And this was all done by myself and my dear friend and colleague, Mary Wood, but we did the entire operation ourselves.
Goran Klintmalm: Tell me then…Tell me how you took the sera and just purified it yourself in the lab and took it upstairs to the patient?
Anthony Monaco: Well with the…With the dog experiments, we used donor with the patients we took the cold serum and precipitated the antiglobulin then filtered it on a porcelain filter to sterilize it and then used the gamma globulin fraction in the patients.
Goran Klintmalm: The same day?
Anthony Monaco: With the dogs, yes. With the patients, I think it was probably within several days considering what we had to do with precipitation and filtration. So the anti-lymphocyte serum experiments were incredibly successful.
And at the same time an opportunity came for me to start my own program at the Harvard Service of the Boston City Hospital, which I did. I was very enthusiastic about getting as much done as I could. And we transferred our laboratory operation there and at the same time expanded the kidney transplant service. One of the things we did at this time, 40 years ago this October was to have the opportunity to start the first Boston inter-hospital organ bank. And we started that with Joe Berry, Francis Moore, John Bannock, Paul Russell and myself.
And this doesn’t sound like much today, but Boston medical institutions are not prone to collaborate, but this was one of the first great examples of this collaboration. And I think that the Boston Organ Bank was a great example for future organ banks. It gradually increased from Boston to surrounding cities, then surrounding New England states. And as you know, it’s the New England Organ Bank now.
Goran Klintmalm: Well it certainly was an enormously impressive people, the people involved were significant to say the least and there were only five but there was. . .
Anthony Monaco: Right. I think there were just five, right.
Goran Klintmalm: But they were not just any five. And I mean obviously the anti-lymphocyte serum was your big triumph I understand, is that correct?
Anthony Monaco: Well I like to think it was maybe one of two. The other one was the utilization of donor bone marrow to induce recipient hyporesponsiveness and prepare the patient to become tolerant. And it’s very gratifying to see these techniques now being used clinically to make patients tolerant.
Goran Klintmalm: Absolutely I think it’s wonderful. Transplant has been central to your entire, obviously and I’m sure it has impacted your life not just professional but it’s been sort of the new, the drive for your professional life, but I’m sure it also impacted your family. Is that so?
Anthony Monaco: Yes I think it’s…
Goran Klintmalm: Can you repeat the question please or some part of the questions?
Anthony Monaco: Well I wonder how to describe about how transplantation has impacted my life. For me, transplantation transcended my career as a surgeon because it permitted me to be a physician, a surgeon, a researcher, and a scientist. And one of the things that was so important in the early days was this whole group of people around the world that were doing this work became a kind of family. And for years our relationships became so close and so intense that in many ways I looked at transplantation almost as my institution as opposed to your total allegiance to a hospital or medical school or a university. I think many of us considered ourselves transplanters as our career, and this meant a great deal to me.
Goran Klintmalm: I couldn’t…I don’t think anyone can say it better. Do you have anything you want to share with ASTS and how you see…? I saw that the forum of where you think we are headed today.
Anthony Monaco: Well I would like a, professional organizations to do anything they can to reinforce each other and to cooperate with each other. I do feel there seems to be a little too much competition amongst professional societies, not just AST and ASTS, but the international sphere, too, and I hope that we can work on that to minimize competition and maximize cooperation.
Goran Klintmalm: Thank you. Thank you so much, Tony that was excellent.
Anthony Monaco: Thank you.
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