New York Neurological Institute observes
its centennial this year.
A neurology house staff alumnus traces
the places connected to one
of American neurology's pioneers
and P&S graduate, Dr. Moses Allen Starr.
By Keith A. Sanders, M.D.
Manhattan witnessed much of the early development of American neurology. Although not widely appreciated, dusty volumes and renovated buildings conceal a storied past. The work of Dr. Moses Allen Starr, one of the leading American neurologists at the turn of the 20th century, provides a valuable perspective on the beginning of American neurology leading up to the creation of the Neurological Institute of New York in 1909. Starr’s writings and the locales of his life remain to offer a glimpse into an active period of growth for American neurology. Many of these neurological landmarks are visible today on a stroll through midtown Manhattan.
Born in Brooklyn in 1854, Starr graduated from the College of New Jersey (Princeton) in 1876 and P&S in 1880. He spent two years at Bellevue Hospital and then studied abroad with Wilhelm Erb and Friedrich Schultze in Heidelberg, with Theodor Meynert and Hermann Nothnagel in Vienna, and with Jean-Martin Charcot in Paris. His laboratory associates in Vienna included Sigmund Freud and Bernard Sachs. After his return from Europe in 1882, he could find no laboratory to continue his microscopic work on the nervous system so he established one in his own house to which students came for instruction.
He became professor of nervous diseases at the New York Polyclinic and served there until 1889 when he resigned to take the chair of nervous diseases in P&S, a position vacated by Dr. Edward Seguin. He held this position until 1917 when he became emeritus. During his time on the P&S faculty, he served as president of the American Neurological Association, in 1896. After retiring, he traveled extensively in Europe. His unpublished memoirs describe vacationing in Switzerland at the outset of World War I and witnessing the frenzy in Rome on the attempted assassination of Mussolini in 1926. He died at the age of 78 in Marienbad, Czechoslovakia.
In addition to fostering Starr’s career, New York City fostered the development of neurology as a medical specialty. Dr. William Hammond, U.S. Surgeon General during the Civil War, and Dr. Edward Seguin, trained by Charcot and Charles-Édouard Brown-Séquard, achieved success in the new specialty of neurology. The 1860s and 1870s saw their early work in New York: Hammond at Bellevue Hospital and Seguin at Columbia and Presbyterian Hospital. When he returned to New York in 1882 after studying abroad, Starr built on the foundations laid by these two men. In 1885 he joined the 50 members of the American Neurological Association founded in New York eight years earlier by Hammond. Neurology at that time had several textbooks and was growing in sophistication.
|Starr’s home, now a landmark, on West 54th Street in Manhattan
Starr’s major contributions to neurology began with a paper on the sensory tracts of the central nervous system. The paper, published in the July 1884 issue of the Journal of Nervous and Mental Disease, earned him the Alumni Association Prize of the College of Physicians and Surgeons. Dr. Smith Jelliffe, American neurology’s first historian, wrote in 1924 that “in this remarkably lucid exposition are seen the broad scientific foundations and the direct method of presentation which have made Starr such a singularly successful and stimulating teacher.” In this paper, called a “milestone” by Jelliffe, Starr studied the neuropathological findings at autopsy of 41 patients with sensory abnormalities. He resolved the longstanding debates about the timing of central nervous system development and whether the cortex was the site of sensory perception.
In the 1870s cerebral localization became the chase of the day and at the 1888 Congress of American Physicians and Surgeons, Starr participated with David Ferrier and Victor Horsely in a symposium on cerebral localization of function. From then on he was regarded as an American pioneer in this field. His special contributions were to sensorimotor neurology, aphasia, and localization of brain tumors, according to a 1953 book, “The Founders of Neurology.” In all, he published more than 100 articles and several textbooks.
In a 2007 review of the history of language localization, neurologist J. van Gijn, writing in the journal Brain, credits Starr with an early understanding of the importance of connecting white matter tracts in the production and recognition of language. He cites Starr’s 1889 article in Brain on sensory aphasia as evidence that Starr was squarely in the camp of the localizationists. Others, such as Pierre Marie and Byron Bramwell, believed in a single language center and that different aspects of language could not be localized at all.
Starr’s skills in localization led him in the late 1880s to begin referring patients with suspected intracranial structural lesions for brain surgery. New York’s booming population and numerous hospitals, clinics, and surgeons fostered this early work on brain surgery. Starr knew of the work of Drs. Horsely and Ferrier in London regarding brain operations for neurological diseases, but most brain surgery at this time was based on visible evidence of cranial disease, such as a fungating tumor or a depressed skull fracture. General surgeons performed these operations. The first American neurosurgeons, surgeons who limit their practice to neurological surgery, would come years later, in the first decade of the 20th century.
|Starr’s skills in localization led him in the late 1880s to begin referring patients with suspected intracranial structural lesions for brain surgery. Starr worked closely with Dr. Charles McBurney, the noted general surgeon 10 years his senior, whose surgical innovations matched Starr’s neurological skills.
Starr worked closely with Dr. Charles McBurney, the noted general surgeon 10 years his senior, whose surgical innovations matched Starr’s neurological skills. McBurney, along with another P&S graduate, William Halsted’1877, began using Lister’s antiseptic surgical techniques in New York hospitals in the 1880s, according to an article published in 2000 in AORN, the journal of the Association of periOperative Registered Nurses. As reported in an earlier issue of P&S Journal, America’s first antiseptic surgical procedure took place in 1876 at Presbyterian Hospital. McBurney had a low postoperative infection rate and was a believer in localization. His ability to make operative decisions based on careful localization of symptoms and signs would come in handy with the cases Starr referred for brain surgery.
McBurney’s work in New York was aided by a large bequest from the will of William J. Syms. This allowed McBurney to construct a model antiseptic surgical pavilion at Roosevelt Hospital. Named for its financial supporter, the Syms Operating Pavilion opened in 1892. McBurney performed craniotomies in this operating theater, still visible today because it achieved landmark status in 1989.
Starr wrote the world’s first textbook on neurological surgery, “Brain Surgery,” in 1893, in which he describes clinical histories and neurological examinations that led to accurate and successful trephination in cases of epilepsy, cerebral hemorrhage, abscess, and tumor. Starr makes the point that proper localization of neurological symptoms can lead to rational, successful brain surgery: “Brain surgery has as its essential basis the accurate diagnosis of cerebral lesions, which was impossible until the localization of cerebral functions had been determined. And this diagnosis must be made by the physician before the surgeon is called in to remove the disease.”
Starr taught neurology to medical students at P&S for 25 years, and for most of those years he was the sole provider of didactic and clinical lectures in diseases of the nervous system for medical students. According to an obituary, his clinical presentations “although lacking in the more theatrical embellishments of the great French neurologist Jean Charcot, were always dramatically impressive. His clinics were invariably crowded by students eager to witness his energetic and convincing demonstration of cases.” A 1915 medical school exam illustrates Dr. Starr’s focus on localization. One question he asked the medical students: “What would be the particular symptoms in a case of apoplexy that would enable you to locate the lesion, (a) in the left internal capsule, (b) in the left frontal region, involving the third frontal convolution, (c) in the right occipital lobe?”
|Syms Operating Pavilion
New York bred and trained him and Starr worked his entire professional life in its hospitals and clinics. The locale made a difference. An appreciation of the geography of Starr’s life adds perspective to his work and to the development of turn-of-the-century neurology in New York. Fortunately, many of the buildings he frequented remain but all but one have been converted to other uses. Starr lived and worked in midtown Manhattan in the years before the subway or the widespread use of motorcars. He took a horse-drawn carriage, streetcar, or walked to his duties.
Starr’s choice of the lot for his home at 5 W. 54th St. typifies his attention to detail. The home was ideally located for a New York physician of the time. It allowed him easy access to the leading medical centers of New York in those years: P&S, which sat adjacent to Vanderbilt Clinic and across the street from Roosevelt Hospital’s Syms Operating Theater on West 59th Street between Columbus and Amsterdam, Presbyterian Hospital on 70th Street between Madison and Park, and the old Neurological Institute of New York at 151 E. 67th St. Starr was a member of the University Club, which was on the corner lot at 54th Street and Fifth Avenue. Dr. William Hammond lived down the block at 43 W. 54th Street but his home is now an Irish pub. If they had not achieved landmark status, Starr’s home, the Syms Operating Theater, the University Club, and the old Neurological Institute would probably have met similar fates.
|Starr taught neurology to medical students at P&S for 25 years, and for most of those years he was the sole provider of didactic and clinical lectures in diseases of the nervous system for medical students.
The block of Starr’s home on West 54th Street between Fifth and Sixth Avenues contains six adjacent landmark buildings from the turn of the 20th century. This is midtown’s only real strip of mansions evoking its days as a neighborhood of millionaires, as described in a New York Times article. On the corner lot sits McKim, Mead and White’s University Club, next door to Starr’s home. Starr engaged prominent New York architect Robert H. Robertson to design his house. A model of “classical refinement and restraint,” the house “is distinguished by elegant detailing and pleasing proportions which are characteristic of the neo-Renaissance style,” noted the New York Landmarks Preservation Commission in designating the residence as a landmark. The architect has seven landmark-designated buildings in New York City, including the Park Row Building, which was the tallest building in the world for nine years until 1908. Starr’s neighbors on the block included John D. Rockefeller Jr. and Philip Lehman of Lehman Brothers fame.
A New York Times article calls the Syms Operating Theater, at the southwest corner of 59th Street and Columbus Avenue, the oldest extant Roosevelt Hospital building. Designed by W. Wheeler Smith, who also designed the long-since demolished College of Physicians and Surgeons building across the street, the mildly Romanesque building’s interior was carefully planned by McBurney to maximize antisepsis. Stop and gaze at this relic. McBurney performed some of the world’s first successful craniotomies here on Starr’s patients. Constructed of deep red brick with granite trim, the building has little decoration, but its unusual great, semiconical skylight on top of a small brick box is memorable. The last operation was performed here in 1941 but passersby can still see its unique design.
|The laboratory named for him at the P&S building in midtown disappeared when the school moved. Although he was widely accepted as one of New York’s top neurologists of the day and lived in the upper echelons of its society, he is largely forgotten.
Dr. Starr’s legacy has a sad aspect. He became professor emeritus of neurology at Columbia in 1915 and continued to see patients for several years. Before the end of his life, Presbyterian Hospital, P&S, Vanderbilt Clinic, and the Neurological Institute of New York moved to the new medical center on 168th Street. The laboratory named for him at the P&S building in midtown disappeared when the school moved. Syms became an apartment building after serving as a blood bank, and the Neurological Institute became a child study center. Starr had one daughter who had no children. Although he was widely accepted as one of New York’s top neurologists of the day and lived in the upper echelons of its society, he is largely forgotten. No diseases or neurological signs are named for him. Ironically, the one place that still bears his name is his home, which is now owned by a private company.
Starr and his colleagues laid the foundations for neurology in midtown Manhattan then saw the work move to other parts of the city. Seeing the old buildings in which Starr practiced neurology 100 years ago makes it visually apparent that neurology moved on. The manner in which the locales changed is analogous to the manner in which neurology changed; the buildings still stand but serve other purposes, and tangible portions of neurology’s history are evident in the way neurology is practiced today. Molecular medicine and modern neuroimaging have not completely supplanted careful bedside history and physical examination to localize the disease process. One hundred years after Starr and his New York colleagues laid the foundations for the new specialty of neurology, modern neurologists intensely pursue new knowledge and treatments and continue to expand on what Starr and others began.
Keith A. Sanders, a resident at the Neurological Institute from 1988 to 1991, is now a neurologist in private practice in Atlanta. He relied on published resources about the history of neurology; historical documents, including Dr. Moses Starr’s unpublished memoirs; materials in Archives & Special Collections of Columbia University Medical Center; and other materials.