Accepted Manuscript

Obituary: Robert M. Eiben, MD (1922-2013)

Robert S. Rust, MA, MD

PII: S0887-8994(14)00258-6

DOI: 10.1016/j.pediatrneurol.2014.04.016

Reference: PNU 8341

To appear in: Pediatric Neurology

Please cite this article as: Rust RS, Obituary: Robert M. Eiben, MD (1922-2013), Pediatric Neurology(2014), doi: 10.1016/j.pediatrneurol.2014.04.016.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service toour customers we are providing this early version of the manuscript. The manuscript will undergocopyediting, typesetting, and review of the resulting proof before it is published in its final form. Pleasenote that during the production process errors may be discovered which could affect the content, and alllegal disclaimers that apply to the journal pertain.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

Obituary: Robert M. Eiben, MD (1922-2013)

Robert S. Rust MA, MD

Charlottesville, VA

Adapted with permission of the Child Neurology Society, St. Paul, MN.

Contact information:

E-mail: RSR6F@hscmail.mcc.virginia.edu

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

Robert M. Eiben (Figure) was born on July 12, 1922 in the near West Side of

Cleveland not far from the City Hospital in which he would spend almost four

decades of his professional life.1 He was a “blue baby” at birth, but his

congenital cardiac disease, thought possibly to be a variant form of tetralogy of

Fallot, was no more exactly diagnosed. At age five he remained sickly, though

he recollected having been somewhat overprotected by his mother. His

parents did at that age allow his tonsillectomy to be performed on the kitchen

table, his father (a businessman) administering ether. Dr. Eiben admitted that his

early professional career evolved more by chance than as the consequence of

planning; his decision to become a physician was based on the combination of

limited endurance and the favorable impression he had formed of physicians

who cared for him.

In 1940 Dr. Eiben enrolled in what became a six year combined B.S./M.D.

program at Adelbert College, Western Reserve University. The work was hard;

he took up pipe smoking because he had difficulty keeping it lit and the

necessity of frequently relighting it kept him awake. While a medical student

Eiben’s externship at Babies and Children’s Hospital confirmed for him that he

wished to be a pediatrician. It also introduced him to Dorothy Crowley, a

student nurse, each apparently quickly becoming attracted to the other.

Although he came into contact with many great teachers, Eiben was

particularly taken with the wisdom, common sense, and leadership of Dr. John

A. Toomey. Dr. Toomey was Director of the Division of Contagious Diseases,

Department of Pediatrics. Dr. Toomey was impressed with Eiben as well; when

he became Acting Chair of Pediatrics in 1945, he invited Eiben to assume the

traditional white button-up doublet in order to serve as an acting intern in the

contagious disease unit of the City Hospital. Official medical internship followed

at the University Hospitals of Cleveland. Although he had decided to become a

pediatrician, Dr. Eiben elected a medicine internship (1946-47), figuring that the

experience would be valuable. However, part of his residency year included

time spent as a Resident in Pediatrics and a Fellow in Infectious Diseases at the

City Hospital of Cleveland

During his internship (unpaid in those days) Eiben and Dorothy Crowley married.

This momentous decision required his leaving the house staff quarters. For

Dorothy the decision to marry was more momentous. The curious regulations of

that time and place did not permit nursing students to marry. Dorothy chose to

resign though she had just one required rotation to complete in order to earn

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

her nursing degree. Her new job in the Accounts Office paid the family bills.

Call for Dr. Eiben was every other night and weekend; there was no vacation for

interns. Nonetheless house staff morale was high. Supported by Dr. Toomey, Dr.

Eiben then earned one of the highly competitive residency positions in the

Cleveland Babies and Children’s Pediatric Residency and Fellowship Program

(1948-1949). These programs had recently come under the direction of a new

Chair of Pediatrics and distinguished infectious disease specialist Charles F.

McKhann, who had pioneered the management of childhood poliomyelitis with

an early artificial respirator. At this promising time of change in the Cleveland

programs, Professor Toomey asked Eiben to resign his academic duties in order

to join him in private practice in Florida, where Toomey planned to move for the

benefit of his wife’s health. The sudden death of Mrs. Toomey eliminated the

need for a move, so Toomey instead asked Eiben to become Instructor in

Pediatrics and Assistant Director of the Division of Contagious Diseases at the

Cleveland City Hospital. This 100-bed hospital had been designed and built in

1910, in the wake of a smallpox and several cholera epidemics, to isolate

patients with contagious diseases.

By 1948 the City Hospital children’s’ wards admitted individuals with many

types of infectious illness ranging from chickenpox and other airborne childhood

exanthemas, mumps, measles, whooping cough, various

meningoencephalitides, scarlet fever, and infectious diarrhea. Nearly 100 cases

of suppurative meningitis were admitted each year, providing Eiben with

considerable experience. Patients with tuberculous meningitis were not

uncommon. When Eiben arrived the mortality rate for infectious meningitis was

about 80%. Within a few exciting years the availability of more effective

antibiotics had significantly reduced this rate to about 17%. Dr. Eiben’s

responsibilities included the care of children and adults with poliomyelitis.

Although mortality was lower than most of the childhood infections, the

possibility of permanent disability, the predilection of polio to strike down healthy

and active children, and the absence of effective treatment methods were

quite frightening to parents. Chronically paralyzed children and those in various

phases of recuperation were found on the polio ward year-round. In the

summertime hundreds of acute poliomyelitis cases littered the admitting area,

triaged “by eyeball” and in various stages of examination and testing. The

characteristic asymmetric flaccid muscle weakness without sensory changes

permitted Dr. Eiben to readily distinguish poliomyelitis from other illnesses. The

start of Dr. Eiben’s career corresponded with a striking rise in the occurrence of

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

poliomyelitis in Cleveland and in many other locations between 1949 and 1955.

In order to be readily available for the evaluation and management of the

children with possible poliomyelitis, Dr. Eiben moved once again into the house

staff quarters. Management involved isolation and in the event of impending

breathing failure, use of the enclosed mechanical ventilator termed the “iron

lung.” Eiben was frequently troubled by the relief some parents expressed after

their child was diagnosed and admitted; he knew too well that severe

deterioration or death might occur in the ensuing few days. Experience of this

sort may account for the sensitivity to parental fear, grief, and guilt to which Dr.

Eiben displayed such exceptional sensitivity during his subsequent career.

Regular re-evaluation of each case by attentive nurses and Eiben was required

to detect signs of impending respiratory failure. This was recognized without

benefit of sophisticated technology to measure vital capacity or blood gases.

Dr. Eiben became exceptionally skilled in assessing muscular tone and an

advocate of the importance of physical therapy. He was aware of the

differences in the pattern of involvement of muscles due to poliomyelitis in

children as compared to adults.

As with other experienced experts in managing this disease, Dr. Eiben was able

to teach his residents the nature and limitations of what could and should be

said to parents. As for the children, Dr. Eiben learned and was able to exemplify,

to the best of his ability, powers to calm and sooth children whose sense of

claustrophobia terrified them as they were being placed in a tank respirator. He

became a master at reading and understanding the minds of little children—

and of their parents. Eiben stressed the importance, improved the approach,

and taught the methods of management that most effectively avoided pain

and the development of pressure sores. He evaluated and employed adaptive

and rehabilitative devices. He particularly recognized the importance of nurses

and of social services. Dr. Eiben became deeply involved in various research

efforts sponsored by the “March of Dimes.”

During his first few years on the faculty, Dr. Toomey remained Dr. Eiben’s most

important teacher. Toomey was renowned for his contributions in pediatric

infectious illnesses, especially poliomyelitis. Toomey’s death from cerebral

hemorrhage in 1950 left a void in Eiben’s professional life, but also an

opportunity. In January of 1950 Dr. Eiben was selected to assume Toomey’s

responsibilities. He was promoted to the position of Acting Director of the

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

Contagious Disease Unit of the Infectious Disease Hospital, which was renamed

the Toomey Pavilion. Six months later McKhann appointed Eiben Acting Director

of the Pediatric Unit at the City Hospital. Eiben recalled his reaction to the such

responsibilities as having been a “very sobering experience.” Eiben also

assumed Toomey’s responsibilities as pediatrician for Parmadale Children’s

Village. His duties chiefly involved rounding at this 500 bed Catholic orphanage

three mornings each week. The energy required to fulfill these obligations was

considerable, yet somehow Dr. Eiben managed to do so despite the exertional

dyspnea, cyanosis, and clubbing due to his tetralogy of Fallot. In 1950, Eiben

was asked to assume an Acting Directorship of the Contagious Diseases and

Pediatrics Wards of the City Hospital due to the retirement of the Director, Dr. J.

D. Pilcher.

Dr. Eiben developed particular expertise in the management of respiratory

failure with the Drinker-style tank respirator. His program in the Toomey Pavilion

was officially designated as a Poliomyelitis Center and he was named the

Center Director. He worked closely with manufacturers to develop and test

various innovations intended to improve the function and convenience of

respirators, including the development of portable devices. Innovations were

applied to the goal of preserving the patency of tracheostomy sites and in the

development of portable positive pressure respirators and plastic cuirass shells

fitted to the trunk that permitted patients to continue mechanical ventilation

outside of the tank ventilator. These innovations opened the way to advancing

patients to home care and to ensuing vocational rehabilitation placement.

In the meantime, Dr. Eiben’s responsibilities for medical students and residents

grew steadily. Moreover, during this busy professional interval his sons Daniel

and Christopher were born. In May of 1952 Frederick Robbins of Harvard arrived

to assume the position of permanent Director of the Toomey Pavilion. At

Harvard, Robbins and Thomas Weller had worked with John Enders to achieve

the important feat of growing polio virus in tissue culture. The three would

receive the 1954 Nobel Prize for this work. The remarkable effectiveness of polio

vaccine, demonstrated in the 1954 field trial, suddenly and permanently ended

many career concentrations in polio research and treatment. More importantly,

the vaccine had an extraordinary effect on the welfare of children worldwide.

More than 2000 polio cases, chiefly a summertime illness, were admitted to the

Toomey Pavilion between 1949 and 1955. That number fell to 80 in 1956, and

new polio cases were rare in 1957 and thereafter non-existent.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

In 1957 Dr. Eiben, as a Center Director of one of the fifteen centers in the United

States for poliomyelitis care and research, was invited to the International

Poliomyelitis Conference in Geneva to deliver a lecture on his experience with

the “Tank Respirator,” by then commonly referred—much to Dr. Eiben’s distress--

as the “Iron Lung.” Dr. Eiben and his colleagues developed complex

nomograms representing the discoveries the group made concerning the

influence of age, weight, sex, activities, and other elements had on achieving

optimal tidal volumes with the tank respirator. Dr. Eiben’s distress with the term

was due to his recognition of the degree to which the machine and the term

polio were disturbing to children and parents. Older children, he found—and

perhaps their parents--were disturbed by the fact that the machine looked

something like a coffin. In addition to sharing this information about the

psychological aspects of employing the respirator, Dr. Eiben provided guidance

concerning the duration of tank episodes and the selection of intervals outside

of the respirator in order to promote rest and sleep. Dr. Eiben characteristically

praised children and their parents for their courage and determination. In

recognition of his contributions in the care of children with poliomyelitis, Dr. Eiben

received the Presidential Award in Geneva.

Upon his return to Cleveland, Dr. Robbins recommended that Eiben consult with

the famous pediatric cardiologist Alexander Nadas at Boston Children’s

concerning his persistent cyanosis, mild clubbing, one-and flight dyspnea

presumed to be due to tetralogy of Fallot. The recommendation, given Dr.

Eiben’s demonstration of remarkable capacity to sustain a quite considerable

set of duties despite these signs, was to wait and watch. In 1958 Eiben became

President of the Medical Staff of the City Hospital, renamed Cleveland

Metropolitan Hospital.

Although he knew a great deal about many CNS infections other than

poliomyelitis, Dr. Eiben was dissatisfied with his preparation as an investigator

and he felt unprepared to assume independent research responsibilities

concerning infectious diseases. Moreover, his work with children with

poliomyelitis had introduced him to the importance of developing a stronger

foundation in the neurological aspects of disease. The development of a

training program for child neurologists, established by Pierce Bailey of the NINDB

on the suggestion of Sidney Carter, provided Eiben with the opportunity he was

seeking. Dr. Eiben approached Sid Carter for a one year fellowship; Carter

advised him to obtain full training in neurology else he would be “neither fish nor

fowl.” Faced with a waiting list (available slots having been filled by future CNS

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

Presidents Dick Allen and Ray Chun, among others) Eiben applied for a 1960

training slot. His application was met with “reservations” on the part of some of

Carter’s associates, possibly because of his age and cardiac status. Carter

himself supported the application—indeed in the future he would refer trainees

seeking a Midwestern program to apply to Eiben. But Eiben developed

subacute bacterial endocarditis in October, 1958. He required one month of

hospitalization with hourly doses of penicillin and intramuscular streptomycin. An

additional two weeks of home parenteral therapy were managed by Eiben’s

wife and by colleagues, employing the recently developed butterfly pediatric

needles for this now veinopenic patient. As Eiben recovered, Dorothy worried

not only about her husband's health but also about the fact that he did not

have life insurance that would help support the family should he die of his serious

illness. She chose therefore to return to nursing school, graduating in short

order. Open heart surgery at the Mayo Clinic in 1959 corrected Eiben’s cardiac

defects.

At a meeting of the Poliomyelitis Center Directors, Eiben explained his training

ambition to Fred Plum, who in response offered Eiben a training position at the

University of Washington’s new NINDB- supported training program directed by

Dr. August G. Swanson. Eiben and his family—now including four sons and two

daughters—drove to Seattle where Eiben trained in neurology for three years.

He found time to investigate neuraminic acids in cultured human skin explants

and published this work in Nature in 1964.2

In 1963 Eiben returned to Cleveland Metropolitan as Director of the Child

Neurology Section of a relatively small but exceptionally fine Neurology

Department that included Maurice Victor and Betty Banker. Dr. Eiben achieved

the rank of Professor of Pediatrics in 1975 and of Neurology in 1985. Dr. Eiben

served as Acting Chief of Clinical investigations and Therapeutics at the

Developmental and Metabolic Neurology Branch of the NINDS from 1976-77. He

became active in the then new Child Neurology Society, serving as its secretary-

treasurer (1978-81) and its twelfth president, the first individual to hold a two year

term from 1983-85. Dr. Eiben served in numerous capacities in his university and

community, paying particular attention to supporting the development of the

library of the Cleveland Academy of Medicine. His generous contributions to the

holdings were made quietly over many years. After the retirements of Drs.

Victor and Banker in 1986, Dr. Eiben continued the Metropolitan neurology

training program as a “one-man show” until his own retirement in 1991. His

service was commemorated by his election to the Cleveland Metro Health Hall

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

of Fame. His commemoratory entry stated “Born frail, Eiben demonstrated the

strength of resolve and dedication as he laid the foundation for a recognized

neurology department at Metro Health while providing compassionate care for

an untold number of young patients.”

During his extraordinarily varied and busy career Robert Eiben published twenty-

one peer-reviewed papers on a wide range of topics, including adrenal

calcification,3 nephrotic syndrome,4 infectious diseases,5 and Guillain-Barre

syndrome.6 Eiben described acute necrotizing encephalopathy in 1967, and his

group’s 2004 description of a genetic locus for vulnerability to acute necrotizing

encephalopathy was his most highly cited paper.7;8 Another highly cited

publication with Betty Banker and Andrew Engel described the clinical and

pathological manifestations of a patient who died from carnitine deficiency.9

Other papers considered ventilator management of individuals with

neuromuscular diseases, including observations concerning non-invasive nasal

ventilation and the complicating features of the ventilation of infantile Type I

spinal muscular atrophy and other conditions . Dr. Eiben was a co-author of the

Child Neurology Society Practice Parameter concerning the persistent

vegetative state.10

Bob Eiben exemplified the importance of advocacy for patients and children.

Long before such things became programmatic, he taught the importance of

awareness of “psychosocial” and ethical elements of human disease. His

experience with a wide variety of severe acute and chronic neurological

diseases, as well as his own illness, prepared him uniquely for such a role. He

worked long hours, but somehow maintained strong commitments to his family

throughout his career. Several years after the death of his first wife, he married

his “high school sweetheart,” bringing together into one family more than a

dozen children. He succeeded in finding time for each of them, including all of

his step-children. Despite various health problems he was an avid fly-fisherman.

A telling measure of the nature of this man was a comment that Phil Dodge

made at the Keystone business meeting of the CNS—an early meeting in an era

where the Society was trying to work out what it was and was meant to be.

During one somewhat heated exchange at the microphones Dodge excused

himself from the company of one individual to go sit next to Eiben. As he did so

he commented “Excuse me--when there is a sticky issue I always sit next to Bob.

Then I can vote the way he does because he will be right.” Dr. Eiben was

honored with the Lifetime Achievement Award of the Child Neurology Society in

2005. Robert Eiben died on December 28, 2013.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

Figure: Dr. Robert M. Eiben is shown in 1994 with two vintage polio respirators

from MetroHealth Medical Center in Cleveland (photograph courtesy of the

Cleveland Plain Dealer).

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT

Reference List

(1) Eiben RM. Reminiscences of an earlier career. J Child Neurol 1996;11:126-132.

(2) Eiben RM, GARTLER SM. NEURAMINIC ACID INVESTIGATIONS OF HUMAN CELL STRAINS DERIVED

FROM EXPLANTS OF SKIN IN CELL CULTURE. Nature 1964;201:1050-1051.

(3) RACK FJ, Eiben RM. Calcification of the adrenal gland in infants and children; differential

diagnosis and report of a case. J Pediatr 1951;39:618-622.

(4) Eiben RM, KLEINERMAN J, CLINE JC. Nephrotic syndrome in a neonatal premature infant; report

of a case. J Pediatr 1954;44:195-202.

(5) ROBBINS FC, Eiben RM. Specific treatment of infectious diseases. Pediatr Clin North Am

1954;405-420.

(6) Eiben RM, Gersony WM. RECOGNITION, PROGNOSIS AND TREATMENT OF THE GUILLAIN-BARR'E

SYNDROME (ACUTE IDIOPATHIC POLYNEURITIS). Med Clin North Am 1963;47:1371-1380.

(7) Eiben RM. Acute brain swelling (toxic encephalopathy). Pediatr Clin North Am 1967;14:797-808.

(8) Neilson DE, Feiler HS, Wilhelmsen KC et al. Autosomal dominant acute necrotizing

encephalopathy maps to 2q12.1-2q13. Ann Neurol 2004;55:291-294.

(9) Engel AG, Banker BQ, Eiben RM. Carnitine deficiency: clinical, morphological, and biochemical

observations in a fatal case. J Neurol Neurosurg Psychiatry 1977;40:313-322.

(10) Ashwal S, Bale JF, Jr., Coulter DL et al. The persistent vegetative state in children: report of the

Child Neurology Society Ethics Committee. Ann Neurol 1992;32:570-576.

MANUSCRIP

T

ACCEPTED

ACCEPTED MANUSCRIPT