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DOI: 10.1055/s-0041-1731307
Professor Frowein
Professor Reinhold A. Frowein died on January 1, 2021, in Cologne at the age of 97. He was born in Bochum on October 5, 1923. After studying at the Universities of Bonn, Germany, and Basel, Switzerland, he passed his final medical examination at the University of Düsseldorf, Germany, in 1949, where he was promoted to Doctor of Medicine with a dissertation on brain tumors and brain hemorrhages. He began his neurosurgical training at the first neurosurgical service installed in Germany after the Second World War, in Bochum Langendreer, where his chief, Prof. Wilhelm Tönnis, had started a Division of Neurosurgery at the department of surgery. He then followed his chief in 1951 to the newly erected Clinic for Neurosurgery at the University of Cologne, which was then the first university department of Germany. One year later, he left for a fellowship in Paris, France, where he studied the new and popular methods of prolonged anesthesia and hypothermia at the Hôpital de la Pitié Salpétrière and the Centre Hospitalier Sainte-Anne. Following fellowship, he returned to Cologne in 1954 where he investigated the effects of these new procedures on neurosurgical operations and on brain injuries at the institute of physiology using animal experiments. After neurosurgical training, he was promoted to the position Oberarzt at the age of 36 years. He attained his habilitation at 38 years and was appointed to Professor of Neurosurgery at the age of 42 years.
In 1969, at the age of 45 years, he was appointed as Chair of Neurosurgery at the University of Cologne where he taught neurosurgery until being emerited in 1989. It was remarkable for that time that he successfully requested operating microscopes for neurosurgical theaters. He was able to publish on his experience with microsurgical pituitary surgery as early as 1972, authoring one of the first papers in the world on this topic.
The care for the critically ill patient was his main mission throughout his entire career. In Bochum-Langendreer, at the Department of Surgery, he had witnessed the establishment of a neurosurgical intensive care unit, which provided the continuous presence of a nurse in the room and ready availability of a physician around the clock. This intensive care ward was the first of its kind in Europe. Intensive care units from other medical specialties in Europe were copies based upon this original model. Fundamental papers on long-term ventilation, pulmonary function, blood gases, and intracranial pressure were published by Frowein and his team during these years in Cologne.
In Germany in 1963, Frowein was the first to report a new phenomenon, which he called “cerebral death.” This described comatose patients, who suffered an irretrievable loss of all brain functions despite best medical efforts, while the already highly effective intensive care unit could maintain the functions of all other organs. A short time later, the expression “brain death” became colloquial for this phenomenon. With the first transplantation of a heart in 1967 in South Africa, a sudden need for organs became obvious and a precise and dependable definition of the criteria for brain death was needed. These were pronounced as recommendations in 1982 by a scientific council of the Bundesärztekammer, a federal board of physicians, with Frowein as a member; consequently, these criteria attained nationwide acceptance. Modifications of these original “recommendations” were added by this council, then chaired by Frowein, and renamed “guidelines.” As medicine progressed, new diagnostic and technical options became available, whereas the clinical neurologic criteria for brain death remained unchanged for decades until now. The fundamental distinction between whole brain death and brain stem death had been precisely elaborated by Prof. Frowein. These profound insights constitute a unique German contribution to the international perception of neurologic death.
Frowein further investigated the fundamental clinical significance of the idea of “coma,” used as synonym of “unconsciousness.” He studied its impact on neurosurgical treatment and prognosis, especially survival, in numerous painstaking studies containing significant case numbers. Upon his initiative, an international group of neurosurgeons, the “Neurotraumatology Committee” of the World Federation of Neurosurgical Societies” (WFNS) coined a definition of the term “coma” and specified the clinical signs of coma.[1] This internationally consented definition has never been challenged even today. It is valid not only for neurosurgery but also for all of medical disciplines and fundamental to neurosurgical guidelines regarding the diagnosis of brain death.
Simultaneously with other neurologic colleagues, between the years of 1966 and 1968, Frowein reported for the first time on preserved spontaneous motion after the diagnosis of brain death.[2] In the 12th century, the physician Maimonides had described preserved motor activities in decapitated humans, yet this had not been reported after the onset of brain death. Such observations questioned the significance of spontaneous motor activity in comatose patients. In the English literature, the first report on such spontaneous movements after brain death surfaced in 1984, almost 20 years later.
The Glasgow Coma Scale (GSC) was originally published in 1974. Its clinical classification valued the loss of motor function in its motor score as the worst clinical sign of neurologic deterioration in comatose patients, as at that time the possibility of spontaneous movements of the brain dead patient had not yet attained common knowledge within the English-speaking world. In light of his findings of spontaneous movements in brain death, Frowein held the GCS as a misleading classification despite its global acceptance. Together with its disregard of pupillary function, Frowein saw it as not helpful in differentiating the relevant signs of the neurologic syndrome “coma.” Brain death was just a new phenomenon medicine had not seen yet. It takes time until new insights are accepted. A German survey of doctors working in emergency medicine from 2008 revealed that the majority of these physicians used the term “coma” only when their patient exhibited no spontaneous movements—a position hard to comprehend after the reports by Maimonides and Frowein. The public opposition to the concept of brain death, often supported by physicians and nurses, mostly relies on the misconception that nobody could reasonably be declared dead while still exhibiting spontaneous movements. With his typically relaxed poise, Frowein responded to this with a quotation from the autobiography of the 85-year-old Max Planck: “A new scientific truth will not prevail by convincing the opponents to a point they accept it, but rather by waiting until these opponents get extinct and the new generation will get used to the truth.”
His interesting lectures were very popular among students and colleagues. They were preceded for days by the busy young doctors and the art laboratory of the department making preparations including detailed descriptions of patients. In 1986, he organized the International Conference on Recent Advances in Neurosurgery (ICRAN) in Cologne. The inaugural meeting was held in Germany and garnered international attention with contributions from all continents.
His scholars trusted Frowein because of his absolute reliability, uncommonly pleasant manners, and his precise scrutiny and discipline during even the most difficult surgical procedures. His enthusiasm and clinical presence, his diligence in his scientific efforts, and his uncompromised support of his colleagues in professional, organizational, and personal matters were well received over his years. One could call Frowein at 3 AM in the morning and receive satisfactory and adequate help.
The daily afternoon meetings with colleagues from radiology, at times quite controversial, were chaired by him with dignity. I am reminded of the presentation of an incidental large olfactory groove meningioma in an 85-year-old lady free of any clinical signs. Upon the discussion of the urgency of surgical management, he simply commented: “Don't!” Despite his advice, the patient insisted on an operation with an excellent early outcome, but succumbed to the postoperative recovery phase 2 weeks later. Another session was interrupted by a young colleague bursting in and asking for help in one of the operating rooms, as the surgeon could not control the bleeding while operating on an intracranial hemorrhage. Prof. Frowein himself got up and took over. Eight hours later and after the infusion of 60 packs of donated blood (we thought this would be the end of the reserves of the blood bank of North Rhine-Westphalia), he had excised the arteriovenous malformation unrecognized prior to surgery. Upon recovery, the patient was able to walk out of the hospital without major deficits.
Frowein wrote scientific articles up to his retirement. The way he developed new ideas was remarkable. One year prior to his retirement, he took some of us to the institute of anatomy to get familiar with a novel system of pedicle screws to stabilize spines, which he then surgically implanted himself some days later. With this commitment obvious to everyone, he acquired an enormous professional and personal authority over the years in his department and the entire medical faculty.
At one of the annual meetings of the German Society of Neurosurgery (Deutsche Gesellschaft für Neurochirurgie [DGNC]), a colleague suggested that we abandon our tradition of changing the location of our annual meetings every year from place to place. It was argued this could facilitate the organization by having the annual meeting in the same place, as done by some other medical specialties. Immediately several colleagues placed their bid to have the meeting in their town. By that time, the 80-year-old Frowein stood up to speak in favor of not changing our tradition. One must know that during his service in Cologne, he himself had taken the heavy burden to organize this annual meeting more often than the usual, that is, twice, in 1977 and in 1988. He claimed that the work of a congress president was challenging and one could learn a lot from this effort. In his experience, this was what keeps a man young. The remark was met with so much laughter that nobody insisted on a vote on this issue.
With the death of Prof. Dr. Reinhold Frowein, the DGNC lost not only one of their former presidents, an honorary member, and the prize winner of the Tönnis-Medaille of 1994 but also the last witness of the stormy development of the early phase of neurosurgery in Germany. Intensive care medicine lost one of their early pioneers. Medicine lost one of their internationally acclaimed clinical researchers. His scholars around the world are grateful for what they have learnt from him.
Publication History
Article published online:
14 July 2021
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References
- 1 Frowein RA. Classification of coma. Acta Neurochir (Wien) 1976; 34 (1–4): 5-10
- 2 Frowein RA, Firsching R. Hirntod-Diagnose in Deutschland. In: Neurochirurgie in Deutschland: Geschichte und Gegenwart. 50 Jahre Deutsche Gesellschaft für Neurochirurgie. Berlin: Blackwell; 2001: 207-218