Professor Reinhold A. Frowein died on January 1^st, 2021 in Cologne at the age of 97. He was born in Bochum on October 5^th, 1923. After studying at the Universities of Bonn and Basel he passed his final medical exam at the University of Düsseldorf in 1949, where he was promoted to Dr. med. 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 constructed Klinik für Neurochirurgie der Universität zu Köln, which was then the first university department of Germany. One year later he left for a fellowship in Paris, where he studied the new and popular methods of prolonged anesthesia and hypothermia at the Hôpital de la Pitié Salpétrière and the Centre Hopitalier 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 Physiologische Institut der Universität zu Köln using animal experiments. After neurosurgical training he was promoted to the position of Oberarzt at the age of 36.  He attained his habilitation at 38 and was appointed to Professor of Neurosurgery at the age of 42.

In 1969, at the age of 45 he was invited to the Chair of Neurosurgery at the University of Cologne where he taught neurosurgery until being emeritus in 1989. It was remarkable for that time that he successfully requested operating microscopes for neurosurgical theatres. He was able to publish 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 nonstop 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 produced by Prof. Frowein and his team during these years in Cologne.

In Germany in 1963, Professor Frowein was the first to report a new phenomenon, which he called “Der zerebrale Tod”, i.e. “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 Prof. Frowein as a member; consequently, these criteria attained nationwide acceptance. Modifications of these original “recommendations” were added by this council, then chaired by Prof. Frowein, and renamed “guidelines”. As Medicine progressed, new diagnostic and technical options became available, while the clinical neurological criteria for brain death remained unchanged for decades. The fundamental distinction between whole-brain death and brain stem death had been precisely elaborated by Prof. Frowein. He insisted on the confirmation of the loss of function of the whole brain instead of the isolated brain stem death, which is accepted in the United Kingdom. Very few patients with primary brain lesions of the posterior fossa may develop coma, apnea and cranial nerve areflexia while an intact Electroencephalography and eventually even visual evoked potentials are preserved. It appeared unacceptable to him to allow the harvesting of organs in these patients, because their state of consciousness cannot be clarified. This view was shared by the majority of physicians involved in the process of defining the criteria of brain death in Germany. These profound insights constitute a unique German contribution to the international perception of neurological death.

Prof. Frowein further investigated the fundamental clinical significance of the idea of “coma”, used as a synonym of “unconsciousness”. He studied its impact on neurosurgical treatment and prognosis, especially survival, in numerous painstaking studies containing significant case numbers. For a neurosurgeon, his interest for rehabilitation was quite unusual. He reported the fundamental relation of posttraumatic duration of coma to the potential of recovery. He could demonstrate that a 10-year old patient had a 5% chance of survival after 3 weeks of uninterrupted posttraumatic coma versus a 70-year old adult after 1 week of coma. After one week of coma, a 10-year old had a 60 % likelihood of reaching a full ability to work in later life and 20 % after two weeks of coma, while a 50-year old patient had a 10% chance to return to his former job after one week of coma and no chance after two weeks of coma. (Frowein RA et al.: Long lasting coma after head injury: late results. Adv Neurosurg 17, 36-42 1989) With a long term follow up after rehabilitation he clearly demonstrated a potential for recovery from neurological and psychological deficits within the first two years after the injury. This information proved to be very encouraging to quite a number of relatives of victims of head injuries (Frowein RA, Firsching R: Personality after head injury. Acta Neurochir. (Wien), Suppl 44, 70-73, 1988). 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 their clinical findings (Frowein R.A.: Classification of Coma. Acta Neurochir [Wien] 34: 5-10, 1976). This internationally consented definition has never been challenged even until today. It is valid not only for neurosurgery but for all of medicine and fundamental to neurosurgical guidelines regarding the diagnosis of brain death.

Simultaneously with other neurological colleagues, between the years of 1966 and 1968, Professor Frowein reported for the first time on preserved spontaneous motion after the diagnosis of brain death (Frowein R.A., Firsching, R.: Hirntod-Diagnose in Deutschland. In: Neurochirurgie in Deutschland: Geschichte und Gegenwart. 50 Jahre Deutsche Gesellschaft für Neurochirurgie, S.207-218,  Blackwell Berlin, Wien 2001). 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 English literature, the first report on such spontaneous movements after brain death surfaced in 1984, almost 20 years later.

The Glasgow Coma Scale was originally published in 1974. Its clinical classification valued the loss of motor function in its motor score as the worst clinical sign of neurological 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, Prof. Frowein held the Glasgow Coma Scale as a misleading classification despite its global acceptance. Together with its disregard of pupillary function, Professor Frowein saw it as not helpful in differentiating the relevant signs of the neurological syndrome “coma”. When the coauthor of the Glasgow Coma Scale, Mr. Jennett, asked about the practicability of Dr. Frowein´s classification of coma into four grades, he drily retorted, the differentiation of 4 grades of the defined syndrome of coma were clearly more simple than the use of a scale of 3 to 15, which failed to define coma.

Brain death was just a new phenomenon medicine had not seen yet. It takes time until new insights are accepted. A current 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 Prof. 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, Prof. 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 ICRAN (International Conference on Recent Advancs in Neurosurgery), sponsored by the Neurotraumatology Committee in Cologne. The inaugural meeting was held in Germany and garnered international attention with contributions from all continents.

His scholars trusted Prof. Frowein because of his absolute reliability, uncommonly pleasant manners, 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. When the administration only offered a part- time job to a secretary, where a full-time job was really needed, he paid for the missing half out of his own private means. One could call Professor Frowein at three o´clock 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’m 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 post-operative recovery phase two 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, at midnight, and after the infusion of 60 packs of donated blood (we thought this would be the end the reserves of the blood bank of Northrhine Westfalia) –  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.

Only a few chiefs of universities write papers in their last 10 years of their service. Professor 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 meetings of the Deutsche Gesellschaft für Neurochirurgie, 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 that this could facilitate the organization by having the annual meeting in the same place, which is habitually 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 Prof. 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 loss of Prof. Dr. Reinhold Frowein, the Deutsche Gesellschaft für Neurochirurgie lost not only one of their former presidents, an honorary member or the prize winner of the Tönnis-Medaille of 1994, but the last witness of the stormy development of the early phase of neurosurgery. The Euroacademia Multidisciplinaria Neurotraumatologica, EMN loses its first honorary member from 1976. 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.

Magdeburg, April 2021,
Prof. Dr. med. R. Firsching
LRCP (Lond.), MRCS (Eng.)
emer. Direktor der Universitätsklinik für Neurochirurgie Magdeburg
Vicepresident of the DGNKN, Member of the EMN