Abstract
UNITED KINGDOM1
Stroke is a relatively recent field. No history of vascular neurology would be complete without the name of John W. Norris. We have lost him to Covid-19, but his contributions continue to have an impact.
He came into the world in Portsmouth, United Kingdom (UK) as the first of three children born to an Irish father and an English mother. He had a rough beginning in school during the Second World War. However, later with the encouragement and help of his family physician, Dr. Duncan, he began studying medicine in Aberdeen, Scotland.He was a 16 year old scholarship student. He graduated in 1957, sharing first place with Derek Ogston, who later became Dean of the Medical School.The search for further training took him across the UK, including a stint with Wilhelm Mayer Gross, a founder of British psychiatry.
After 5 years with the British army and postings in Germany, he ended up in Leeds on the neurology service of Maurice Parsonage and Hugh Garland. After training in neurology, he found no consultant positions and decided to emigrate. Parsonage had contacts in the Montreal Neurologic Institute (MNI) and arranged for John to become a fellow there in 1967.
CANADA1
At the MNI, in addition to his clinical rotations, he worked in the laboratory of Dr. Hannah Pappius on experimental cerebral ischemia.
In 1970 he became a consultant in neurology at the Sunnybrook Medical Centre (SMC). I had met him in Montreal as a first year resident in internal medicine rotating through the MNI.When I returned to Toronto to train in neurology, I spent 6 months at Sunnybrook. John was a great teacher and researcher. It was mainly because of him that I accepted a faculty position at the SMC.
John was intent on setting up an acute stroke unit, although two had been opened and closed in the United States, as they did not seem to help patients. His wish to have a stroke unit became possible when Colonel Graham MacLachlan, one of John’s grateful patients, gave him nearly $1 million. Establishing the unit proved a formidable task. Skepticism and insidious opposition obstructed the path. Despite this, we managed to assemble a group of enthusiastic volunteer nurses, physiotherapists, occupational therapists and speech therapists. Josephine Sommerville, a rehabilitation specialist, agreed to visit the stroke unit every day and decide what each patient neededfor their optimal rehabilitation. Either John or I examined every patient, every day in meticulous detail and jumped on any complication. Even before we analyzed our statistics, we knew that fewer patients were dying and more were going home. Several factors contributed to this. One was the comprehensive and continuous care and in retrospect there was another factor. Jo Sommerville believed that rehabilitation of stroke patients began on day one and she mobilized the patients early.
I learned the intra-arterial xenon 133 technique to determine cerebral blood flow (CBF) in London, UK and Copenhagen and John learned the technique easily from me. We tried to contribute to the understanding of ischemic pathophysiology, but the xenon technique proved insufficient. However, fortuitously we did contribute to an understanding of migraine pathophysiology. Before the days of computer tomography, cerebral angiography was the preferred method of studying the brain. Injecting contrast material was the most reliable, if unintended, way of triggering a migraine attack. The prevailing view was that the aura was due to vasoconstriction, the decreased blood flow led to the accumulation of lactic acid that produced vasodilation and the headache.
We confirmed the sequence in a young woman. We gave her ergotamine, the headache stopped, but the CBF remained high. Ergotamine was supposed to be a cerebral vasoconstrictor, but obviously it was acting through another mechanism. We confirmed this finding in a series of patients, thus discrediting the prevailing view and nudging migraine research into more productive directions.
After 5 years at the SMC, I moved to London, Canada, but John and I continued to collaborate.I established the second acute stroke unit in Canada at University Hospital on the SMC model and then John and I went on to dismantle another prevailing view and practice: high dose corticosteroids as a treatment of acute stroke. Our controlled randomized clinical trial with patients from our respective stroke units showed that high dose corticosteroid treatment was useless and dangerous, encouraging the pursuit of more fruitful avenues.
We decided to share what we learned by contributing a book on acute stroke to the Contemporary Neurology Series that was setting high standards for neurology. We agreed on an outline. I was off to a quick start and sent several chapters to John. He was supposed to edit them. After I finished drafting my chapters, he produced his first chapter, almost perfect in content and language. After he finished writing his chapters, he began savaging mine. Our friendship came to the brink. I had not fully appreciated John’s perfectionist streak under what one of his commanding officers called “Casual and off-hand manner” when he was a Captain in the British army.
Fortunately his perfectionism made “The Acute Stroke” a better book that proved useful to others in the growing field of stroke. It was translated into several languages. Later, we went on to edit two books on stroke prevention.
John had set up an ultrasound laboratory, and with Brian Chambers, his stroke fellow, produced a landmark study published in the New England Journal of Medicine showing that asymptomatic carotid disease has a relatively benign prognosis, sparing tens of thousands of patients from an unnecessary operation. Later he led a multi-center study showing that although seizures were common after stroke, persistent seizures were rare, sparing patients unnecessary drug treatments.
He founded the Canadian Stroke Consortium, (CSC) bringing all 45 Canadian stroke centers under one umbrella to carry out controlled clinical trials. The CSC has fostered collaboration among Canadian stroke neurologists and allied professionals, has set high standards, and has a major impact on education of residents and fellows in stroke. (https://strokeconsortium.ca/home) His vision in founding and leading the CSC might be one his greatest, living and growing contributions. John and I secured and presided over the 5th International World Stroke Congress in Vancouver, Canada in 2004. By the time of the 11th World Stroke Congress held in Montreal in 2018, the CSC was led by a new generation of stroke leaders under the Presidency of Michael Sharma. John was honoured at the Congress that turned out to be his unintended goodbye.
In addition to the many scientific contributions, he leaves behind many pupils, friends and admirers, as was evident during the Congress.
John usually impressed those whom he met. He dressed impeccably, spoke with precision and could discuss intelligently almost any subject, leavened by a wry sense of humour. Once, he and I were waiting to get into a restaurant while attending a stroke conference, when an attractive woman told him that she loved his English accent and that he looked like the Duke of Edinburgh. John kept his British upper lip stiff, but his lower lip curled into a satisfied slight smile.
He was a great companion, a connoisseur, a bon vivant, kind, cultivated and witty. We cannot have more conversations with John, but we can recall some of the highlights in fond memory of him.
PUPILS ON FOUR CONTINENTS2
I had the honour and pleasure to be John W. Norris' stroke fellow at Sunnybrook Medical Center in Toronto, following Brian Chambers' steps in one of John’s most important research projects on asymptomatic carotid stenosis. I spent three amazing years (1984–87) as a stroke fellow with him. John was an outstanding physician, a wonderful mentor, and an intelligent gentleman with a very unique sense of humour that we all appreciated. He was a great teacher and very generous mentor. I remember how excited and nervous I was before my first presentation at the International Stroke Conference, especially being a non-native English speaker. John patiently rehearsed with me for hours to make sure that my presentation was perfect. The same applied to his meticulous review of the articles that I wrote together with him. He was kind enough to support my attendance at many international conferences where he introduced me to the “big wheels” (his words) and thus paved my international career. Upon my return to Tel-Aviv I established the first Israeli stroke unit, stroke registry and Doppler laboratory, implementing John's rules and principles. Beside the academic achievements, together we also established a successful series of bi-annual International Conferences on Stroke (1996–2006). I can definitely say that I owe John my entire international career. I am sure that his many fellows (25) from 4 continents share the same views and feelings for our “academic father”, a mentor, a gentleman, a colleague and friend whom we will all miss and remember.
RETURN OF A NATIVE3
After retirement in Canada, John returned full time to the UK. However he was still keen to be involved in Neurology and Stroke. I was aware of John’s international reputation and had met him a few times, being friends with a number of his research fellows particularly Chris Bladin and Andrei Alexandrov. Therefore I was delighted when John agreed to join us at St. George’s, University of London, where I had recently been appointed to the chair of Neurology. In 2003 he was awarded an Emeritus Professorship of Neurology there. He took on regular teaching for the medical students, which was very well received, but was also keen to stay involved in research. He had already established a track record in carotid and vertebral artery dissection, showing that this was followed by a transiently increased risk of stroke, and this led to us successfully applying to the Stroke Association for a grant to set up the CADISS trial. This compared antiplatelet agents with anticoagulation in preventing recurrent stroke in recent carotid and vertebral dissection. It was great fun working on this together and after a few years longer than expected, as is the case with many clinical trials, we completed the trial. It still provides the only good data on how to manage this group of patients, and is a further testament to John’s impact on clinical stroke care. After I moved to Cambridge in 2013, John continued to attend clinical meetings at St. George’s whilst carrying out an active medicolegal practice. We continued to work together on CADISS and dissection and our last joint paper came out in 2019 describing the final CADISS results.
During our time together at St. George’s John was a good friend and mentor. It was particularly helpful to have someone with his wealth of experience at a time when I was setting up a new department and facing many new challenges. John always provided a wise opinion both on academic and non-academic matters, with advice such as ‘Hugh, no-one wishes they had published more papers on their deathbed.’ He was supportive to, and well liked by, the members of Clinical Neurosciences Department and comments widely used by people he worked with their since his death include ‘a gentleman and a gentle man’ and ‘a kind man’. We all enjoyed his wry British sense of humour.
Courtesy of Andrei V Alexandrov 2018