Robert M. Eiben, MD (1922-2013)

By Robert S. Rust MA, MD

1979 CNS Executive Committee, on which Dr. Eiben served as Secretary-treasurer. Front Row (L-R): Drs. Paul Dyken, Arthur Prensky, N. Paul Rosman, Robert Eiben; Back Row (L-R): Drs. Gerald Golden, Gerald Erenberg, John Freeman, Mary Anne Guggenheim. Dr. Freeman passed away the week following Dr. Eiben's death. A tribute written by Dr. Rust will appear on this website on March 14.

1979 CNS Executive Committee, on which Dr. Eiben served as Secretary-treasurer. Front Row (L-R): Drs. Paul Dyken, Arthur Prensky, N. Paul Rosman, Robert Eiben; Back Row (L-R): Drs. Gerald Golden, Gerald Erenberg, John Freeman, Mary Anne Guggenheim. Dr. Freeman passed away the week following Dr. Eiben's death. A tribute written by Dr. Rust will appear on this website on March 14.

Robert M. Eiben was born on July 12, 1922 in the near West Side of Cleveland, not many blocks from the City Hospital in which he would spend almost forty years of his professional life. 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, however, allow a tonsillectomy to be performed on the five-year-old atop the kitchen table, with 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 he enrolled in what became a six-year combined BS/MD program at Adelbert College, Western Reserve University. The work was hard. He took up pipe smoking because he had difficulty keeping it lit; he found the need to frequently relight 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 became attracted to the other.

Although he came into contact with many great teachers, Eiben was particularly taken with the wisdom, common sense, and leadership demonstrated by Dr. John A. Toomey. Dr. Toomey was Director of the Division of Contagious Diseases, Department of Pediatrics. Dr. Toomey was particularly impressed with Eiben, so much so that 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; part of his residency year, however, 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) Dr. Eiben married Ms. Crowley. 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, although she had just one required rotation left to complete in order to earn 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 from Boston Children’s’ Hospital, Charles F. McKhann. Among other accomplishments in his career, Dr. McKhann had pioneered the management of childhood poliomyelitis with an early artificial respirator. At this interesting and very promising time of change in the Cleveland programs, Professor Toomey asked Dr. Eiben to resign his academic duties in order to join him in the private practice of pediatrics in Florida. Dr. Toomey had decided to move there for his wife’s health. The sudden death of Mrs. Twoomey eliminated the need for a move. Dr. Twoomey instead asked Dr. Eiben to join him as 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 to isolate patients with contagious disease in the wake of one smallpox and several cholera epidemics.

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. Cases of tuberculous meningitis were not uncommon. On Eiben’s arrival the mortality rate for infectious meningitis was about 80%. Within a few years very exciting years the availability of more effective antibiotics had significantly reduced this rate to about 17%. Included among Dr. Eiben’s critical responsibilities was his selection to provide care specific to the needs of children and adults with poliomyelitis. Although mortality was lower than most of the childhood infections, the possibility of permanent disability, the predilection of this disease to strike down healthy and active children, and the absence of effective methods of controlling or treating the illness 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 poliomyelitis in Cleveland and in many other locations from 1949-1955.

In order to be readily available for the evaluation and management of the considerable number of children admitted 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.” It is an ironic tribute to Salk and Sabin that these and other commonplace signs have become bewildering to current neurology board candidates. 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 and other “psychiatric” aspects of disease to which Dr. Eiben has displayed such exceptional sensitivity during his subsequent career. Regular re-evaluation of each case by attentive nurses and by Eiben was required to detect signs of impending breathing failure. This was recognized without benefit of sophisticated technology for the measurement of vital capacity or blood gas monitors. Dr. Eiben became exceptionally skilled in assessing muscular tone and a forceful advocate of the importance of ever-improving approaches to physical therapy. He was aware of the differences in the pattern of involvement of muscles due to poliomyelitis in children as compared to adults.

A particularly important problem for which Dr. Eiben had to assume responsibility in caring for children with poliomyelitis was the uncertainty of outcome. He found the early stages of this illness particularly troubling in that early recognition of the development of weakness and prompt admittance of a child for hospital management was never reassuring. Parent’s eagerness to be reassured by the early admittance in mild stages of illness was something that Dr. Eiben could never honestly satisfy at that time. As with other experienced and capable 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 the ability to calm and soothe 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. Dr. 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. As a result of Dr. Eiben’s responsibilities for the diagnosis of infectious diseases, he became deeply involved in various research efforts, sponsored by the “March of Dimes.” His duties included giving lectures to medical students, residents, and student nurses as an expert in diagnosis of infectious diseases. For the hospital he was responsible for administering the then-available small panel of diagnostic tests including that for tuberculosis, as well as the Dick test for immunocompetence and resistance to scarlet fever, and the Schick test for diphtheria susceptibility.

During his first few years on the faculty, Dr. Toomey remained Dr. Eiben’s most important teacher. He was world renowned for his contributions in fields ranging through the length and breadth of pediatric infectious illnesses, especially acute anterior poliomyelitis. He had authored over 300 publications. Toomey’s death from stroke in 1950 left a considerable void in Eiben’s professional life, but also opened up 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 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 being 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. Dr. Eiben worked closely with specialized manufacturing operations 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. The success of Eiben’s facility even led to the transport of adult patients from distant locations for their polio and ensuing rehabilitation to be managed. One such individual, an American PhD in biology who contracted polio in the mountains of Iran, was transported to Cleveland where, despite his quadriplegia, he was able to employ a mouth stick page-turner and dictating machine to continue his career of scientific publication.

Meanwhile, Dr. Eiben’s responsibilities for medical students and residents tended to grow and grow. Moreover, during this busy professional interval two sons were born to the Eiben family, Daniel and Christopher. 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 of 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. In 1956 that number fell to 80. Remarkably, new cases of polio were rare in 1957 and thereafter non-existent.

In 1957 Dr. Eiben, as a 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 that time commonly referred to—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 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 the return to Cleveland of this extraordinarily hard-working physician, Dr. Robbins recommended that Dr. 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 demonstrated capacity to sustain a 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 forms of CNS infection 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, which he found quite interesting. The announcement of the very new development of a training program for child neurologists, established by Pierce Bailey of the NINDB on the suggestion of Sid Carter, provided him 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 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. Unfortunately, in October of 1958 Eiben developed subacute bacterial endocarditis in October, 1958. He required one month of hospitalization with high hourly doses of penicillin and intramuscular streptomycin. An additional two weeks of treatment at 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.

As he recovered and attended a meeting of the Poliomyelitis Center Directors, Eiben explained his training ambition to Fred Plum. Plum offered Eiben a training position at the University of Washington’s newly established NINDB supported training program directed by Dr. August G. Swanson. Open heart surgery at the Mayo Clinic in 1959 corrected Eiben’s cardiac defects. Concerned about the future of the pediatric respiratory medicine program at Metropolitan, Eiben participated in the recruitment of another “polio doctor” familiar with ventilatory intensive care, Avron “Bud” Sweet. Dr. Sweet embarked, among other things, on an ambitious program of expansion of intensive care that produced a premiere neonatology unit for the University Hospitals. Dr. 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 engage in basic investigations of neuraminic acids in cultured human skin explants. This work was published in Nature in 1964.

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. He served as Acting Chief of Clinical investigations and Therapeutics at the Developmental and Metabolic Neurology Branch of the NINDS from 1976-77. Quite active in the Child Neurology Society, he was elected Secretary-Treasurer (1978-81) and became the Society’sTwelfth President–it’s first 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 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.”

Over his extraordinarily various and busy career Dr. Eiben has published twenty-one peer-reviewed original papers from 1951-2004 concerning a wide variety of topics. Some concerned adrenal calcification (1951), neonatal or infantile nephrosis (1954), diagnosis and treatment of infectious (1954, 1957). Inflammatory diseases such as Guillain-Barre (1963), acute necrotizing encephalopathy (ANE: 1967, 2003, 2004), or post-immunization neurodegeneration (1978) considered cause, management, and outcome of these conditions, among which Dr. Eiben’s 2004 report of the genetic locus for vulnerability to ANE was his most highly cited paper. Heritable metabolic conditions to which papers were devoted including the highly cited consideration of human cellular variation in neuraminic acids in human cell cultures already noted (1964), another quite highly highly cited publication with Betty Banker and Andy Engel concerning clinical, biological, and pathological characteristics discerned in a fatal case of carnitine deficiency, the clinical, radiological, and pathological characteristics of adrenoleukodystrophies (1977, 1980, 1980), those of mucopolysaccharidosis Type IIIB (1978), and an interesting case of case of mitochondropathy with seizures (1978). Several papers considered approaches to ventilator management, especially of neuromuscular conditions, including wise observations concerning non-invasive nasal ventilation (1997), and the complicating features of the ventilation of infantile Type I spinal muscular atrophy (1998) and other neuromuscular conditions (1999). It is likely the case that Dr. Eiben was the wisest and most adept manager and expert concerning the provision of mechanical respiratory support to infants and children among all modern child neurologists. Dr. Eiben was one of the co-authors of the AAN Practice Parameter concerning the persistent vegetative state (1992).

Bob Eiben’s greatest impact as a teacher may be the unwavering passion with which he advocated for patients and children. Long before such things became programmatic, he taught and exemplified the importance of a keen awareness of the various “psychosocial” and ethical elements of human disease. His experience with a wide variety of severe acute and chronic neurological diseases, including his own personal 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, Bob 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 Phil Dodge made at the 1978 CNS business meeting in Keystone, an early meeting in an era where the society was trying to work out what it was and what it 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, commenting as he did so, “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 in 2005 with the presentation of the Lifetime Achievement Award of the Child Neurology Society at its annual meeting in Los Angeles. He died on December 28, 2013.