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In memoriam: Dr Norman M. Kaplan (1931–2020)

Ram, C. Venkata S.a,b,c

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doi: 10.1097/HJH.0000000000002503
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A giant in the field of hypertension has departed.

The Guru, the Almanac, the Encyclopedia, and the Legend of hypertension -- Dr Norman Kaplan passed away on 5 April 2020 in Dallas, Texas, USA. He spent his entire professional career at the University of Texas Southwestern Medical School in Dallas -- except for a year at the National Institutes of Health.

Norman's parents had a small grocery store in Dallas; and the son of a grocer went on to become a peerless global commander in the field of hypertension. A graduate of the University of Texas Southwestern Medical School in 1954, he trained at the same institution in Internal Medicine and Endocrinology. After a year of collaborative work at NIH with the renowned Dr Fred Bartter (of Bartter’ s syndrome), Norman joined the faculty of his alma mater -- in 1961 -- where he remained until 2015. Upon stepping down, he told a medical reporter ‘Sixty-one years is enough’!

Norman's scientific contributions to the field of hypertension are extraordinary; although he lived for 90 calendar years, his impact on the field of hypertension will be felt for a long time. The majority of his contributions to the field of hypertension are well known and recorded. Therefore, I would like to draw attention and comment on some of his ‘characteristic’ but less widely publicized articles. Amazingly, he identified some of the precursors of aldosterone synthesis (Journal of Clinical Investigation 1962; 41:715–724) and actually measured the aldosterone content of adrenal adenoma (Journal of Clinical Investigation 1967; 46:728–734). It is because of his insight that random sampling of urine for metanephrine to screen for pheochromocytoma became an acceptable substitute for the laborious 24-h urine collections (Archives of Internal Medicine 1977; 137:190–193).

It was he who further strengthened the Irvine Page ‘Mosaic’ theory of hypertension, by demonstrating persistent sympathetic activity in hypertension despite volume expansion and suppression of plasma renin activity (Annals of Internal Medicine 1970; 72:9–16). Norman was one of the earliest investigators to describe the metabolic syndrome (Archives of Internal Medicine 1989; 149:1514). He was known for fearlessly and vigorously expressing his views on controversial topics without any hesitation. For example, he argued that it is the blood pressure, which is of paramount importance, not the level of plasma renin, and thus opposed measuring plasma renin activity for the selection of antihypertensive drugs in the classical commentary ‘Renin profiles: the unfulfilled promises’ (JAMA 1977; 288:611–613). He almost resolved the dilemma for the choice of diuretic in treatment by writing an eloquent commentary ‘Chlorthalidone versus hydrochlorothiazide: a tale of tortoise and hare’ (Hypertension 2011; 58:994–99).

To call Norman a prolific writer is an understatement; his numerous publications are literary gems in the modern medical literature. And of course, his famous book ‘Clinical Hypertension’ remains the most authoritative, beloved, and admired book in hypertension. Now in its 11th edition, it still remains number 1 and has been translated into 10 languages! The common thread throughout all his writings is -- clarity, completeness, and scientific integrity.

Norman received countless honors from many countries in the world, too numerous to mention. Amongst his most prized honors were the Lifetime Achievement Award of the AHA -- Council for High Blood Pressure Research and, ISH Stevo Julius Award for scientific communications and many, many more. He also served on several Joint National Committees for hypertension guidelines.

A true humanist, Norman's enthusiasm, work ethics, loyalty, dependability, punctuality, and mannerisms were exemplary. He was an epitome of ‘gentleness’ and a shining example for the medical profession.

A tireless advocate of social justice, Norman supported the local community generously. And he made no secret of his political affiliations and viewpoints. Once, he hung a life-size portrait of a USA Presidential candidate outside his office. I asked him, if such a display was permitted in a public institution? And he quipped ‘no one has asked me to take it down’, and I thought, with Norman, who would?

My first memory of Norman takes me back to 1975–1976 when I was a resident at Brown University, Providence, Rhode Island. I had to prepare for a noon conference on hypertension and read parts of Norman's book (the first edition). I needed to create a figure from his book and was unsure whether it was legal to copy something from a book without the author's permission. Nervously, I wrote a formal letter to Norman asking for his permission. Promptly, I received a handwritten reply ‘sure and best wishes’ with his signature! This simple gesture was the first and only step, which led to my association with him for over three decades. When I completed my Fellowship, he invited me to join him at the University of Texas South Western Medical School in 1977 and we worked together from then onwards.

I am blessed and fortunate to have worked with him for so many years. From him, I learnt the basics and advances in medical education, clinical research, and communication. When stuck with designing a clinical trial, Norman would walk in and give advice in minutes. Once, he asked me to clinically test that a high-salt intake can aggravate diuretic induced hypokalemia; lo and behold, we confirmed this in a clinical trial (Archives of Internal Medicine 1981; 141:1015–1019). And with his astute analytical mind, we showed for the first time in clinical medicine 24-h blood pressure control using automated ambulatory blood pressure monitoring (Current Therapeutic Research 1980; 28:88).

Norman did not think that calcium supplements lowered blood pressure and we reported this finding in a clinical trial (American Journal of Medical Sciences 1987; 294:219–224). We confirmed his belief that gradual reduction in blood pressure in the elderly does not reduce cerebral blood flow (American Journal of Medicine 1987; 82 (IA):53–57). In every study, I did, Norman's input and footprints were of immense value. My career advanced with his advice and guidance.

Norman had a creative capacity to guide his colleagues and staff in the right direction. For example, he directed me to clinical hypertension (not laboratory science), created a basic science laboratory for Celso Gomez- Sanchez and Bryan Holland, and for the late Ron Victor and Wanpen Vongpatanasin (current hypertension chief in Dallas), he provided a hybrid of laboratory and clinical research space. Each of us followed the pathways drawn by Norman to fit our individual abilities. And we still continue to stay the course!

Norman was preceded in death by his lovely wife Audrey; his adorable surviving family members include daughters Marcia, Cynthia, Carolyn, and Diane and stepsons Michael and Daniel, who all witnessed their father's impeccable character and unblemished values which will serve them well.

Good-bye, Norman. Rest in peace. Your legacy lives on.

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