Neuro-Ophthalmology Matthew J.

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Neuro-​Ophthalmology
ii

What Do I Do Now?

S E R I E S C O -​E D ITORS-​I N-​C HIE F

Lawrence C. Newman, MD
Director of the Headache Division
Professor of Neurology
New York University Langone
New York, New York

Morris Levin, MD
Director of the Headache Center
Professor of Neurology
University of California, San Francisco
San Francisco, California

OT H E R VO L U M E S IN T HE SE RIE S
Headache and Facial Pain
Epilepsy
Pain
Emergency Neurology
Neuroinfections
Neurogenetics
Neurotology
Pediatric Neurology
Neurocritical Care
Stroke
Peripheral Nerve and Muscle Disease
Cerebrovascular Disease
Movement Disorders
Women’s Neurology
Neuroimmunology
iii

Neuro-​Ophthalmology

SECOND EDITION

Matthew J. Thurtell, MBBS, FRACP

Associate Professor of Ophthalmology and Neurology
Director of Neuro-​Ophthalmology Service
Department of Ophthalmology and Visual Sciences
University of Iowa
Iowa City, IA

Robert L. Tomsak, MD, PhD

Professor of Ophthalmology and Neurology
Kresge Eye Institute
Wayne State University
Detroit, MI

1
iv

1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
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Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© Oxford University Press 2019
First Edition published in 2011
Second Edition published in 2019
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging-​in-​Publication Data
Names: Thurtell, Matthew J., author. | Tomsak, Robert L., author.
Title: Neuro-ophthalmology / by Matthew J. Thurtell, Robert L. Tomsak.
Description: Second edition. | New York, NY : Oxford University Press, [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2018054874 | ISBN 9780190603953 (pbk.)
Subjects: | MESH: Eye Diseases—diagnosis | Nervous System Diseases—complications |
Cranial Nerve Diseases | Eye Diseases—therapy | Diagnosis, Differential | Case Reports
Classification: LCC RE75 | NLM WW 460 | DDC 617.7075—dc23
LC record available at https://lccn.loc.gov/2018054874
This material is not intended to be, and should not be considered, a substitute for medical or other
professional advice. Treatment for the conditions described in this material is highly dependent on
the individual circumstances. And, while this material is designed to offer accurate information with
respect to the subject matter covered and to be current as of the time it was written, research and
knowledge about medical and health issues is constantly evolving and dose schedules for medications
are being revised continually, with new side effects recognized and accounted for regularly. Readers
must therefore always check the product information and clinical procedures with the most up-​to-​date
published product information and data sheets provided by the manufacturers and the most recent
codes of conduct and safety regulation. The publisher and the authors make no representations or
warranties to readers, express or implied, as to the accuracy or completeness of this material. Without
limiting the foregoing, the publisher and the authors make no representations or warranties as to the
accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do
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or incurred as a consequence of the use and/​or application of any of the contents of this material.
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Printed by WebCom, Inc., Canada
v

Robert B. Daroff, MD—​our mentor, colleague, and friend—​in

recognition of his contributions to the field of neuro-​ophthalmology.
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Contents

Preface ix

Acknowledgments xi

SECTION I AFFERENT DISORDERS

1 Optic Neuritis 3

2 Arteritic Ischemic Optic Neuropathy 9

3 Nonarteritic Ischemic Optic Neuropathy 15

4 Compressive Optic Neuropathy 21

5 Leber Hereditary Optic Neuropathy 25

6 Autosomal Dominant Optic Atrophy 29

7 Neuroretinitis 35

8 Papilledema 41

9 Idiopathic Intracranial Hypertension 47

10 Pseudopapilledema 55

11 Chiasmal Syndromes 61

12 Homonymous Hemianopia 67

13 Disorders of Higher Visual Function 71

14 Visual Auras, Hallucinations, and Illusions 77

15 Transient Vision Loss 83

16 Unexplained Vision Loss 89

17 Nonorganic Vision Loss 93

SECTION II EFFERENT DISORDERS

18 Third Nerve Palsy 99

19 Fourth Nerve Palsy 105

20 Sixth Nerve Palsy 111

21 Intermittent Diplopia 115

vi

22 Ocular Myasthenia 121

23 Infranuclear Ophthalmoplegia 127

24 Internuclear Ophthalmoplegia 133

25 Supranuclear Ophthalmoplegia 137

26 Gaze-​Evoked Nystagmus 141

27 Downbeat Nystagmus 145

28 Upbeat Nystagmus 151

29 Pendular Nystagmus 155

30 Infantile Nystagmus 161

31 Saccadic Intrusions and Dysmetria 167

SECTION III EYELID DISORDERS

32 Eyelid Ptosis 175

33 Benign Essential Blepharospasm 181

SECTION IV PUPIL DISORDERS

34 Anisocoria 187

35 Horner Syndrome 193

36 Tonic Pupil 199

SECTION V ORBITAL AND MISCELLANE O U S D I S O RD E R S

37 Thyroid Eye Disease 207

38 Syndromes of the Orbital Apex, Superior Orbital Fissure, and

Cavernous Sinus 213

39 Carotid-​Cavernous Fistula 219

40 Dorsal Midbrain Syndrome 225

Index 231

viii Contents
ix

Preface

Patients with neuro-​ophthalmic conditions are commonly encountered

in clinical practice, yet many clinicians feel ill prepared or uncomfortable
when dealing with them. Those trained in neurology often feel uneasy when
evaluating patients who have predominantly visual or ocular complaints,
whereas those trained in ophthalmology often feel uncomfortable when
evaluating those with predominantly neurologic complaints. Since a
neuro-​ophthalmologist is not always available for consultation, the clini-
cian might be left wondering, “What do I do now?” when encountering a
challenging case.
In this installment of the What Do I Do Now? series, we aim to pro-
vide a user-​friendly manual that clinicians can reference when dealing with
patients who have neuro-​ophthalmic problems. The volume is divided into
five sections that cover the main subdivisions of neuro-​ophthalmic prac-
tice: (1) afferent (visual) disorders, (2) efferent (eye movement) disorders,
(3) eyelid disorders, (4) pupil disorders, and (5) orbital and miscellaneous
disorders. Each chapter includes a practical, case-​based discussion on how
to approach and manage a patient with a particular disorder. We discuss
mainly common disorders, although we also consider some less common
yet important conditions, as well as neuro-​ophthalmic presentations of sys-
temic and psychiatric disease. We have included a large number of efferent
(eye movement) cases because many other handbooks focus on afferent
(visual) disorders. We have based our recommendations on current evidence
whenever possible. A list of key clinical points appears at the end of each
chapter as well as a list of important references. In most chapters, tables
and boxes summarize pertinent information. We include figures in most
chapters to illustrate abnormal clinical signs or relevant imaging findings.
We designed the volume as a resource for neurologists and
ophthalmologists at all levels of training. We hope that it will serve as a
useful handbook in caring for patients with neuro-​ophthalmic disease.
x
xi

Acknowledgments

Many of the cases described in this book touch on controversial aspects

of neuro-​ophthalmology. We acknowledge those experts in the field who
agreed to discuss their personal approaches to such cases with us. In par-
ticular, we thank Drs. Randy H. Kardon, Michael Wall, Richard C. Allen,
and Wallace L. Alward for their helpful advice. We also thank the team at
Oxford University Press, Craig Panner and Tiffany Lu, for their help in
bringing this volume to completion.
xi
1

SECTION I

Afferent Disorders
2
3

1 Optic Neuritis

You are called to see a 22-​year-​old woman

who has had a subacute onset of vision
loss in her right eye over several days with
associated pain on eye movements. She
has no past medical history and denies
other neurologic symptoms. Examination
shows visual acuities of 20/​100 in the
right eye and 20/​15 in the left eye. She
can identify only the control Ishihara
color plate with the right eye, but she
correctly identifies all plates with the left
eye. Confrontation visual fields show a
central scotoma in the right eye. Her pupils
are equal and react to light, but there is a
right relative afferent pupillary defect. Her
funduscopic examination is normal.

What do you do now?

3
4

T he patient in this scenario has had a subacute onset of painful mo-

nocular vision loss and exhibits the cardinal signs of an optic neurop-
athy: decreased visual acuity, a central visual field defect, dyschromatopsia,
and a relative afferent pupillary defect. Her presentation is classic for optic
neuritis. The clinical manifestations of optic neuritis vary depending on
the portion of the optic nerve that is inflamed. For example, in retrobulbar
optic neuritis, the most common subtype of optic neuritis, the retrobulbar
portion of the optic nerve is inflamed and there is minimal, if any, optic disc
edema. However, in neuroretinitis, the optic nerve head and peripapillary
retina are inflamed, giving rise to optic disc edema and changes in the
macula (i.e., fluid extending into the macula initially with development of
retinal exudates to form a macular star) (see Case 7).
Causes for optic neuritis also vary depending on the portion of the optic
nerve affected. Causes for retrobulbar optic neuritis include demyelinating
diseases (e.g., multiple sclerosis [MS] and neuromyelitis optica), auto-
immune diseases (e.g., systemic lupus erythematosus), inflammatory
diseases (e.g., sarcoidosis), infections (e.g., Lyme disease and syphilis),
and vaccinations (e.g., influenza vaccine). In many patients, however, a
cause cannot be identified and the optic neuritis is considered idiopathic.
Nevertheless, the first step in the evaluation of the patient described in
this scenario would be to obtain further history (e.g., inquiring about re-
cent travel, vaccinations, and tick bites). The ophthalmic and neurologic
examinations should be completed, because there may be abnormalities that
suggest the diagnosis. For example, the presence of granulomatous uveitis
on ophthalmic examination might suggest an inflammatory disorder, such
as sarcoidosis, whereas the presence of internuclear ophthalmoplegia might
suggest MS. In the absence of any other significant history or abnormal
examination findings, however, the optic neuritis is likely to be idiopathic.
Diagnostic studies should be obtained in patients with idiopathic optic
neuritis to confirm the presence of optic nerve enhancement, to evaluate for
white matter lesions in the brain, and to exclude other causes for the optic
neuropathy (e.g., compressive optic neuropathy; see Case 4). The most im-
portant initial diagnostic study is magnetic resonance imaging (MRI) of the
orbits and brain. MRI of the orbits typically demonstrates increased signal
in the affected optic nerve, with associated contrast enhancement that is
best appreciated on fat-​suppressed images (Figure 1.1). However, such

4 WHAT DO I DO NOW? Afferent Disorders

5

FIGURE 1.1. MRI of the orbits (top row) and brain (bottom row) in a patient with optic neuritis,
demonstrating left optic nerve enhancement and multiple ovoid periventricular white matter
lesions consistent with MS.

changes are nonspecific and cannot be considered diagnostic of idiopathic

optic neuritis. MRI of the brain should be obtained to assess for white
matter lesions, which are most obvious on the T2-​weighted and FLAIR
(fluid-​attenuated inversion recovery) sequences (see Figure 1.1), because
the presence of one or more lesions (especially when they have a periven-
tricular distribution) portends an increased risk of developing MS.
Laboratory investigations can be useful to screen for other causes of optic
neuritis, such as neuromyelitis optica (NMO), especially in patients with
atypical features to their presentation (Box 1.1). Patients with optic neuritis
in the setting of NMO with NMO-​IgG (i.e., aquaporin-​4) antibodies often
present with severe vision loss that can be bilateral and without associated
pain, and a poor recovery of vision despite aggressive treatment. Patients

1. Optic Neuritis 5
6

FIGURE 1.2. MRI of the orbits in a patient with bilateral optic neuritis in the setting of
neuromyelitis optica, demonstrating longitudinally extensive bilateral optic nerve enhancement.

with optic neuritis in the setting of NMO with myelin oligodendrocyte

glycoprotein (i.e., MOG-​IgG) antibodies can also present with severe vision
loss that can be bilateral with associated optic disc edema, but usually have
a rapid and dramatic recovery of vision with treatment. With optic neuritis
in the setting of NMO, MRI of the orbits can show longitudinally exten-
sive optic nerve enhancement or bilateral optic nerve enhancement (Figure
1.2). Other laboratory investigations, such as antinuclear antibody, anti-​
neutrophil cytoplasmic antibodies, angiotensin-​converting enzyme level,
lysozyme level, syphilis serology, and Lyme serology, are often unrevealing
and, thus, unnecessary unless there are atypical features to the presentation
(see Box 1.1). Cerebrospinal fluid (CSF) analysis can be useful to evaluate
for other causes of optic neuritis in selected patients. However, CSF analysis

BOX 1.1 Atypical Features for Idiopathic Optic Neuritis

Lack of pain
Severe vision loss
Poor recovery of vision
Bilateral optic nerve involvement
Systemic symptoms or signs (e.g., fever or rash)
Intraocular inflammation, hemorrhages, or exudates
Immunocompromised patient (e.g., transplant recipient)
Longitudinally extensive optic nerve enhancement on MRI
Optic nerve sheath enhancement on MRI
Rapid improvement following initiation of steroids
Relapsing course following withdrawal of steroids

6 WHAT DO I DO NOW? Afferent Disorders

7

is not routinely required to evaluate for oligoclonal bands and other CSF
markers of MS, because an increased risk of MS is more reliably predicted
by the presence of white matter lesions on MRI.
The recommended treatment of idiopathic optic neuritis is based on the
findings of the Optic Neuritis Treatment Trial, which was a randomized
controlled trial comparing outcomes in patients who received intravenous
and then oral steroids, oral steroids alone, or placebo. The group receiving
intravenous and then oral steroids showed a more rapid recovery of vision
than the placebo group, although the final visual outcome was similar. This
group also showed a lower risk of developing clinically definite MS in the
first 2 years following treatment. The group receiving oral steroids alone did
not show a faster recovery compared with placebo but did show an increased
rate of recurrent optic neuritis attacks compared with the other two groups.
Thus, the recommended treatment protocol for idiopathic optic neuritis
is intravenous methylprednisone (1 g daily) for 3 days followed by oral
prednisone (1 mg/​kg daily) for 11 days. The prognosis for visual recovery is
excellent, with vision recovering to near normal in most patients over weeks
to months, although there can be minor persisting visual deficits (e.g., in
contrast and color vision) and clinical signs of optic nerve dysfunction (e.g.,
a relative afferent pupillary defect and optic disc pallor).
In patients who have one or more white matter lesions on MRI, the risk
of developing MS is greater than 65% in the 15 years following an attack of
idiopathic optic neuritis, compared with 25% in patients who do not have
white matter lesions. Treatment with disease-​modifying therapy for MS
(e.g., beta-​interferon) can reduce the risk of developing MS in patients with
idiopathic optic neuritis who have white matter lesions on MRI. Although
not all optic neuritis patients with white matter lesions will develop clini-
cally definite MS, initiation of disease-​modifying therapy should be care-
fully considered.

KEY POINT S TO REMEMBER

• The cardinal signs of an optic neuropathy are decreased visual

acuity, a central visual field defect, dyschromatopsia, and a
relative afferent pupillary defect.

1. Optic Neuritis 7
8

• Optic neuritis is characterized by a subacute onset of painful

monocular vision loss with a relative afferent pupillary defect;
optic disc edema may or may not be present, depending on the
portion of the nerve affected.
• Optic neuritis is often idiopathic but can be caused by
demyelinating disease, autoimmune disease, inflammatory
disease, infections, and vaccinations.
• MRI of the orbits and brain should be obtained acutely to
confirm the presence of optic nerve enhancement, evaluate for
white matter lesions in the brain, and exclude other causes of
optic neuropathy.
• The 15-​year risk of developing MS is over 65% in optic neuritis
patients with one or more white matter lesions on MRI versus
about 25% in those with no white matter lesions.
• Treatment of optic neuritis with intravenous methylprednisone
(1 g daily) for 3 days and then oral prednisone (1 mg/​kg daily)
for 11 days leads to a faster recovery of vision and decreased
risk of developing MS in the 2 years following treatment.

Further Reading
Beck RW, Cleary PA, Anderson MM Jr, et al. A randomized, controlled trial of
corticosteroids in the treatment of acute optic neuritis. N Engl J Med.
1992;326:581–​588.
Beck RW, Cleary PA, Trobe JD, et al. The effect of corticosteroids for acute optic
neuritis on the subsequent development of multiple sclerosis. N Engl J Med.
1993;329:1764–​1769.
Chen JJ, Flanagan EP, Jitprapaikulsan J, et al. Myelin oligodendrocyte glycoprotein
antibody (MOG-​IgG)-​positive optic neuritis: clinical characteristics, radiologic
clues and outcome. Am J Ophthalmol. 2018;195:8–​15.
Optic Neuritis Study Group. Multiple sclerosis risk after optic neuritis: final optic
neuritis treatment trial follow-​up. Arch Neurol. 2008;65:727–​732.
Thompson AJ, Banwell BL, Barkhof F, et al. Diagnosis of multiple sclerosis: 2017
revisions of the McDonald criteria. Lancet Neurol. 2018;17:162–​173.

8 WHAT DO I DO NOW? Afferent Disorders

9

2 Arteritic Ischemic
Optic Neuropathy

A 75-​year-​old white woman presents to

your clinic after suddenly developing vision
loss in her right eye. She reports having
had several brief episodes of transient
vision loss in her right eye over the past
week, as well as a persistent dull right-​
sided temporal headache. Examination
shows visual acuities of count fingers in
the right eye and 20/​25 in the left eye. She
cannot identify the control Ishihara color
plate with the right eye, but she correctly
identifies all plates with the left eye. Her
pupils are equal and react to light, but there
is a right relative afferent pupillary defect.
Funduscopic examination shows pallid
optic disc edema in the right eye.

What do you do now?

9
10

T he acute onset of severe monocular vision loss with associated pallid

optic disc edema in this older woman with temporal headaches should
immediately suggest anterior ischemic optic neuropathy secondary to
giant cell arteritis (GCA). Ischemic optic neuropathies occur as a result of
hypoperfusion of the optic nerve. Ischemia to the retrobulbar portion of
the nerve results in posterior ischemic optic neuropathy; because the ante-
rior portion of the optic nerve is not affected, there is no associated optic
disc edema. Ischemia to the anterior portion of the nerve results in ante-
rior ischemic optic neuropathy; because the optic nerve head is affected,
there is, by definition, optic disc edema, which can be hyperemic or pallid.
Anterior ischemic optic neuropathy occurs more frequently than posterior
ischemic optic neuropathy. It can be divided into two types: arteritic an-
terior ischemic optic neuropathy (AAION), in which the ischemia results
from inflammatory narrowing or occlusion of the posterior ciliary arteries
by vasculitis (most commonly GCA), and nonarteritic anterior ischemic
optic neuropathy (NAION), in which the ischemia occurs because of other
factors (see Case 3).
GCA is a granulomatous vasculitis that affects medium-​to large-​sized
arteries, especially the cranial branches of the aortic arch. It occurs most
commonly in white women who are aged 65 years or more and does not
occur in children or adults who are aged 50 years or less. Up to 50% of
patients present with visual symptoms, mostly secondary to AAION. The
AAION in GCA is characterized by a rapid onset of severe monocular vi-
sion loss with diffuse optic disc edema (Figure 2.1) and a dense relative
afferent pupillary defect. The vision loss is often devastating, with the ini-
tial visual acuity being count fingers or worse in over 50% of patients. The
optic disc edema is typically pallid, but it can be hyperemic. The optic disc
edema gradually resolves over several weeks, with the optic disc ultimately
becoming pale, atrophic, and cupped. In contrast with optic neuritis and
NAION (see Cases 1 and 3), there is rarely any recovery of vision. AAION
can sometimes be difficult to distinguish from NAION in the acute set-
ting. The distinction is clinically important, however, because 25% to 50%
of patients with AAION will develop AAION in the fellow eye within 2
weeks if left untreated. The presence of pallid optic disc edema is highly
suggestive of AAION, whereas hyperemic optic disc edema with retinal
nerve fiber layer hemorrhages is more characteristic of NAION (see Case

10 WHAT DO I DO NOW? Afferent Disorders

1

FIGURE 2.1. Fundus photograph demonstrating pallid optic disc edema due to AAION, with
cilioretinal artery occlusion, in a patient with GCA (left). Fluorescein angiography shows patchy
choroidal nonperfusion and cilioretinal artery occlusion (right).

3). Since GCA causes inflammatory narrowing and occlusion of the poste-
rior ciliary arteries (which supply the choroid of the eye) and the cilioretinal
artery (which variably supplies the papillomacular portion of the retina),
concurrent choroidal or cilioretinal ischemia is highly suggestive of GCA
(see Figure 2.1). Prior to the onset of AAION, a significant proportion of
patients will have episodes of transient monocular or binocular vision loss,
which are typically precipitated by postural changes. Some patients expe-
rience transient diplopia, which is thought to be secondary to ischemia
of the extraocular muscles. Many report systemic symptoms, such as tem-
poral headache, jaw claudication, scalp tenderness, malaise, weight loss, and
fever, which should immediately suggest GCA. However, their absence does
not preclude GCA; over 20% of patients with biopsy-​proven GCA do not
have systemic symptoms.
For the patient in this scenario, with a dull temporal headache and se-
vere monocular vision loss due to anterior ischemic optic neuropathy, the
clinical suspicion for GCA is high. Therefore, urgent investigations and
treatment are required. An erythrocyte sedimentation rate and C-​reactive
protein level should be obtained immediately. Most patients with GCA
have elevation of both inflammatory markers, reflecting systemic inflam-
mation, but occasionally only one might be elevated. In patients who do
not have elevated inflammatory markers, further investigations should still
be obtained and empiric treatment initiated if the clinical suspicion for

2. Arteritic Ischemic Optic Neuropathy 11

12

GCA is high. Fluorescein angiography can be useful to demonstrate cho-

roidal or cilioretinal ischemia, thereby helping to differentiate AAION from
NAION (see Figure 2.1). However, the diagnosis can be confirmed only by
identifying the characteristic histopathologic changes on temporal artery
biopsy. The specimen should be at least 2 cm long and serially sectioned,
to avoid a false-​negative result in the event that there are skip lesions. If the
clinical suspicion is low, a negative biopsy is sufficient to exclude the diag-
nosis. The initiation of treatment should not be delayed while awaiting a
temporal artery biopsy or its result; the histopathologic changes persist for
at least several weeks after treatment is commenced.
In any patient with suspected AAION, systemic corticosteroids should
be administered immediately to reduce the risk of AAION occurring in the
fellow eye. Although no prospective randomized study has been performed,
many clinicians treat with intravenous methylprednisone (1 g daily) for 1–​
3 days followed by high-​dose oral prednisone (1 mg/​kg daily), although some
will begin with high-​dose oral prednisone alone. High-​dose oral prednisone
should be continued for at least a month, until systemic symptoms have re-
solved and the inflammatory markers have normalized. When prednisone is
used as monotherapy, its dose should be slowly tapered over 12–​18 months
(e.g., by 5–​10 mg per month), provided that the patient does not have any
symptoms to suggest active GCA and his or her inflammatory markers remain
within normal limits. Since many patients develop significant complications
and side effects from prolonged prednisone therapy (e.g., osteoporosis, steroid-​
induced diabetes, and weight gain), addition of a steroid-​sparing agent (e.g.,
leflunomide) should be considered. One recent trial found that therapy with
tocilizumab, a monoclonal antibody to the interleukin-​6 receptor, allowed for
a more rapid taper of prednisone with less serious adverse events than therapy
with prednisone alone. However, long-​term follow-​up is needed to determine
the durability of remission with tocilizumab and its long-​term safety.

KEY POINTS TO REMEMBER

• AAION is characterized by a rapid onset of severe monocular

vision loss with a relative afferent pupillary defect and pallid or
hyperemic optic disc edema.

12 WHAT DO I DO NOW? Afferent Disorders

13

• AAION occurs because of inflammatory narrowing or occlusion

of the posterior ciliary arteries by vasculitis (e.g., GCA).
• GCA is a granulomatous vasculitis that most commonly occurs
in older white women.
• Systemic symptoms of GCA include temporal headache, jaw
claudication, scalp tenderness, malaise, weight loss, and fever.
• About 50% of patients with GCA present with vision loss, in
most cases due to AAION.
• High-​dose corticosteroid treatment should be commenced
immediately whenever GCA is suspected and should not be
delayed while awaiting the results of laboratory studies or
temporal artery biopsy.

Further Reading
González-​Gay MA, García-​Porrúa C, Llorca J, et al. Visual manifestations of
giant cell arteritis: trends and clinical spectrum in 161 patients. Medicine.
2000;79:283–​292.
Hayreh SS, Zimmerman B. Management of giant cell arteritis: our 27-​year clinical
study: new light on old controversies. Ophthalmologica. 2003;217:239–​259.
Kawasaki A, Purvin V. Giant cell arteritis: an updated review. Acta Ophthalmol.
2009;87:13–​32.
Parikh M, Miller NR, Lee AG, et al. Prevalence of a normal C-​reactive protein with an
elevated erythrocyte sedimentation rate in biopsy-​proven giant cell arteritis.
Ophthalmology. 2006;113:1842–​1845.
Stone JH, Tuckwell K, Dimonaco S, et al. Trial of tocilizumab in giant-​cell arteritis. N
Engl J Med. 2017;377:317–​328.

2. Arteritic Ischemic Optic Neuropathy 13

14
15

3 Nonarteritic Ischemic
Optic Neuropathy

An overweight 58-​year-​old man presents

to the emergency department after waking
with vision loss in his right eye without
associated pain. He has a past history
of hypertension, diabetes, and erectile
dysfunction, and he is taking multiple
antihypertensive medications. Examination
shows visual acuities of 20/​50 in the right
eye and 20/​20 in the left eye. He correctly
identifies 10 of 14 Ishihara color plates with
the right eye and 14 of 14 plates with the
left eye. Confrontation visual fields show
an inferior altitudinal defect in the right
eye. His pupils are equal in size and react
to light, but there is a right relative afferent
pupillary defect. Funduscopic examination
shows superior segmental optic disc edema
in the right eye and a small, structurally
congested optic disc in the left eye.

What do you do now?

15
16

T he acute onset of painless monocular vision loss with associated seg-

mental optic disc edema in this middle-​aged man with multiple vas-
cular risk factors suggests nonarteritic anterior ischemic optic neuropathy
(NAION). NAION is the most common cause of acute-​onset optic neu-
ropathy in older adults in the Western world. It typically produces a rapid
onset of painless monocular vision loss that worsens over hours to days,
with a relative afferent pupillary defect and optic disc edema (Figure 3.1).
An inferior altitudinal visual field defect is often present, although other
visual field defects (e.g., superior altitudinal, arcuate, or central) can also
occur. The optic disc edema is typically segmental (e.g., superior greater
than inferior; see Figure 3.1) and gradually resolves over weeks, with the
optic disc ultimately becoming pale in a segmental fashion. The visual
acuity and field defects usually stabilize in the days following onset. In con-
trast with optic neuritis (see Case 1), there is rarely a substantial recovery of
vision thereafter, although there can be a modest improvement. There is a
small risk of recurrence in the affected eye, but there is a significant risk of
NAION occurring in the fellow eye (15–​20% over 5 years), which patients
should be warned about.
NAION occurs due to hypoperfusion and ischemia of the optic nerve
head. In contrast with the arteritic form (AAION; see Case 2), where vas-
culitis leads to narrowing and occlusion of the arteries supplying the optic

FIGURE 3.1. Fundus photographs demonstrating optic disc edema due to NAION in the right eye
and a small, structurally congested optic disc (“disc at risk”) in the left eye.

16 WHAT DO I DO NOW? Afferent Disorders

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Wrightson Jones, John C. Lear.”
The authenticity of this bill of sale is attested
by N. Harrington, a justice of the peace of the
state of Maryland, and for the county of Talbot,
dated same day as above.

* * * * *
“To all whom it may concern: Be it known that
I, Hugh Auld, of the city of Baltimore, in Baltimore
county in the state of Maryland, for divers good
causes and considerations, me thereunto
moving, have released from slavery, liberated,
manumitted, and set free, and by these presents
do hereby release from slavery, liberate,
manumit, and set free, my negro man, named
Frederick Baily, otherwise called Douglass,
being of the age of twenty-eight years, or
thereabouts, and able to work and gain a
sufficient livelihood and maintenance; and him
the said negro man, named Frederick
Douglass, I do declare to be henceforth free,
manumitted, and discharged from all manner of
servitude to me, my executors and
administrators forever.
 “In witness whereof, I the said Hugh Auld,
have hereunto set my hand and seal the fifth of
December, in the year one thousand eight
hundred and forty-six.
Hugh Auld.
“Sealed and delivered in presence of T.
Hanson Belt, James N. S. T. Wright.”

Having remained abroad nearly two years, and being about to

return to America, not as I left it—a slave, but a freeman, prominent
friends of the cause of emancipation intimated their intention to make
me a testimonial both on grounds of personal regard to me, and also
to the cause to which they were so ardently devoted. How such a
project would have succeeded I do not know, but many reasons led
me to prefer that my friends should simply give me the means of
obtaining a printing press and materials, to enable me to start a
paper, advocating the interests of my enslaved and oppressed
people. I told them that perhaps the greatest hindrance to the
adoption of abolition principles by the people of the United States,
was the low estimate everywhere in that country placed upon the
negro as a man: that because of his assumed natural inferiority,
people reconciled themselves to his enslavement and oppression, as
being inevitable if not desirable. The grand thing to be done,
therefore, was to change this estimation, by disproving his inferiority
and demonstrating his capacity for a more exalted civilization than
slavery and prejudice had assigned him. In my judgment a tolerably
well conducted press in the hands of persons of the despised race,
would by calling out and making them acquainted with their own
latent powers, by enkindling their hope of a future, and developing
their moral force, prove a most powerful means of removing
prejudice and awakening an interest in them. At that time there was
not a single newspaper regularly published by the colored people in
the country, though many attempts had been made to establish
such, and had from one cause or another failed. These views I laid
before my friends. The result was, that nearly two thousand five
hundred dollars were speedily raised towards my establishing such a
paper as I had indicated. For this prompt and generous assistance,
rendered upon my bare suggestion, without any personal effort on
my part, I shall never cease to feel deeply grateful, and the thought
of fulfilling the expectations of the dear friends who had given me
this evidence of their confidence, was an abiding inspiration for
persevering exertion.
Proposing to leave England, and turning my face toward America
in the spring of 1847, I was painfully reminded of the kind of life
which awaited me on my arrival. For the first time in the many
months spent abroad, I was met with proscription on account of my
color. While in London I had purchased a ticket, and secured a berth,
for returning home in the Cambria—the steamer in which I had come
from thence—and paid therefor the round sum of forty pounds,
nineteen shillings sterling. This was first cabin fare; but on going on
board I found that the Liverpool agent had ordered my berth to be
given to another, and forbidden my entering the saloon. It was rather
hard after having enjoyed for so long a time equal social privileges,
after dining with persons of great literary, social, political, and
religious eminence, and never, during the whole time, having met
with a single word, look, or gesture, which gave me the slightest
reason to think my color was an offense to anybody—now to be
cooped up in the stern of the Cambria, and denied the right to enter
the saloon, lest my presence should disturb some democratic fellow-
passenger. The reader can easily imagine what must have been my
feelings under such an indignity.
This contemptible conduct met with stern rebuke from the British
press. The London Times, and other leading journals throughout the
United Kingdom, held up the outrage to unmitigated condemnation.
So good an opportunity for calling out British sentiment on the
subject had not before occurred, and it was fully embraced. The
result was that Mr. Cunard came out in a letter expressive of his
regret, and promising that the like indignity should never occur again
on his steamers, which promise I believe has been faithfully kept.
 CHAPTER VII.
TRIUMPHS AND TRIALS.

New Experiences—Painful Disagreement of Opinion with old Friends—Final

Decision to Publish my Paper in Rochester—Its Fortunes and its Friends
—Change in my own Views Regarding the Constitution of the United
States—Fidelity to Conviction—Loss of Old Friends—Support of New
Ones—Loss of House, etc., by Fire—Triumphs and Trials—Underground
Railroad—Incidents.

PREPARED as I was to meet with many trials and perplexities on

reaching home, one of which I little dreamed was awaiting me. My
plans for future usefulness, as indicated in the last chapter, were all
settled, and in imagination I already saw myself wielding my pen as
well as my voice in the great work of renovating the public mind, and
building up a public sentiment, which should send slavery to the
grave, and restore to “liberty and the pursuit of happiness” the
people with whom I had suffered.
My friends in Boston had been informed of what I was intending,
and I expected to find them favorably disposed toward my cherished
enterprise. In this I was mistaken. They had many reasons against it.
First, no such paper was needed; secondly, it would interfere with my
usefulness as a lecturer; thirdly, I was better fitted to speak than to
write; fourthly, the paper could not succeed. This opposition from a
quarter so highly esteemed, and to which I had been accustomed to
look for advice and direction, caused me not only to hesitate, but
inclined me to abandon the undertaking. All previous attempts to
establish such a journal having failed, I feared lest I should but add
another to the list, and thus contribute another proof of the mental
deficiencies of my race. Very much that was said to me in respect to
my imperfect literary attainments, I felt to be most painfully true. The
unsuccessful projectors of all former attempts had been my
superiors in point of education, and if they had failed how could I
hope for success? Yet I did hope for success, and persisted in the
undertaking, encouraged by my English friends to go forward.
I can easily pardon those who saw in my persistence an
unwarrantable ambition and presumption. I was but nine years from
slavery. In many phases of mental experience I was but nine years
old. That one under such circumstances should aspire to establish a
printing press, surrounded by an educated people, might well be
considered unpractical if not ambitious. My American friends looked
at me with astonishment. “A wood-sawyer” offering himself to the
public as an editor! A slave, brought up in the depths of ignorance,
assuming to instruct the highly civilized people of the north in the
principles of liberty, justice, and humanity! The thing looked absurd.
Nevertheless I persevered. I felt that the want of education, great as
it was, could be overcome by study, and that wisdom would come by
experience; and further (which was perhaps the most controlling
consideration) I thought that an intelligent public, knowing my early
history, would easily pardon the many deficiencies which I well knew
that my paper must exhibit. The most distressing part of it all was the
offense which I saw I must give my friends of the old Anti-Slavery
organization, by what seemed to them a reckless disregard of their
opinion and advice. I am not sure that I was not under the influence
of something like a slavish adoration of these good people, and I
labored hard to convince them that my way of thinking about the
matter was the right one, but without success.
From motives of peace, instead of issuing my paper in Boston,
among New England friends, I went to Rochester, N. Y., among
strangers, where the local circulation of my paper—“The North
Star”—would not interfere with that of the Liberator or the Anti-
Slavery Standard, for I was then a faithful disciple of Wm. Lloyd
Garrison, and fully committed to his doctrine touching the pro-slavery
character of the Constitution of the United States, also the non-
voting principle of which he was the known and distinguished
advocate. With him, I held it to be the first duty of the non-
slaveholding States to dissolve the union with the slaveholding
States, and hence my cry, like his, was “No union with slaveholders.”
With these views I came into western New York, and during the first
four years of my labors here I advocated them with pen and tongue,
to the best of my ability. After a time, a careful reconsideration of the
subject convinced me that there was no necessity for dissolving the
“union between the northern and southern States;” that to seek this
dissolution was no part of my duty as an abolitionist; that to abstain
from voting was to refuse to exercise a legitimate and powerful
means for abolishing slavery; and that the Constitution of the United
States not only contained no guarantees in favor of slavery, but on
the contrary, was in its letter and spirit an anti-slavery instrument,
demanding the abolition of slavery as a condition of its own
existence, as the supreme law of the land.
This radical change in my opinions produced a corresponding
change in my action. To those with whom I had been in agreement
and in sympathy, I came to be in opposition. What they held to be a
great and important truth I now looked upon as a dangerous error. A
very natural, but to me a very painful thing, now happened. Those
who could not see any honest reasons for changing their views, as I
had done, could not easily see any such reasons for my change, and
the common punishment of apostates was mine.
My first opinions were naturally derived and honestly
entertained. Brought directly, when I escaped from slavery, into
contact with abolitionists who regarded the Constitution as a
slaveholding instrument, and finding their views supported by the
united and entire history of every department of the government, it is
not strange that I assumed the Constitution to be just what these
friends made it seem to be. I was bound not only by their superior
knowledge to take their opinions in respect to this subject, as the
true ones, but also because I had no means of showing their
unsoundness. But for the responsibility of conducting a public
journal, and the necessity imposed upon me of meeting opposite
views from abolitionists outside of New England, I should in all
probability have remained firm in my disunion views. My new
circumstances compelled me to re-think the whole subject, and study
with some care not only the just and proper rules of legal
interpretation, but the origin, design, nature, rights, powers, and
duties of civil governments, and also the relations which human
beings sustain to it. By such a course of thought and reading I was
conducted to the conclusion that the Constitution of the United
States—inaugurated “to form a more perfect union, establish justice,
insure domestic tranquility, provide for the common defense,
promote the general welfare, and secure the blessings of liberty”—
could not well have been designed at the same time to maintain and
perpetuate a system of rapine and murder like slavery, especially as
not one word can be found in the Constitution to authorize such a
belief. Then, again, if the declared purposes of an instrument are to
govern the meaning of all its parts and details, as they clearly
should, the Constitution of our country is our warrant for the abolition
of slavery in every State of the Union. It would require much time
and space to set forth the arguments which demonstrated to my
mind the unconstitutionality of slavery; but being convinced of the
fact my duty was plain upon this point in the farther conduct of my
paper. The North Star was a large sheet, published weekly, at a cost
of $80 per week, and an average circulation of 3,000 subscribers.
There were many times, when in my experience as editor and
publisher, I was very hard pressed for money, but by one means or
another I succeeded so well as to keep my pecuniary engagements,
and to keep my anti-slavery banner steadily flying during all the
conflict from the autumn of 1847 till the union of the States was
assured and emancipation was a fact accomplished. I had friends
abroad as well as at home who helped me liberally. I can never be
too grateful to Rev. Russell Laut Carpenter and to Mrs. Carpenter,
for the moral and material aid they tendered me through all the
vicissitudes of my paper enterprise. But to no one person was I more
indebted for substantial assistance than to Mrs. Julia Griffiths Crofts.
She came to my relief when my paper had nearly absorbed all my
means, and was heavily in debt, and when I had mortgaged my
house to raise money to meet current expenses; and by her
energetic and effective management, in a single year enabled me to
extend the circulation of my paper from 2,000 to 4,000 copies, pay
off the debts and lift the mortgage from my house. Her industry was
equal to her devotion. She seemed to rise with every emergency,
and her resources appeared inexhaustible. I shall never cease to
remember with sincere gratitude the assistance rendered me by this
noble lady, and I mention her here in the desire in some humble
measure to “give honor to whom honor is due.” During the first three
or four years my paper was published under the name of the North
Star. It was subsequently changed to Frederick Douglass’ Paper in
order to distinguish it from the many papers with “Stars” in their titles.
There were “North Stars,” “Morning Stars,” “Evening Stars,” and I
know not how many other stars in the newspaper firmament, and
some confusion arose naturally enough in distinguishing between
them; for this reason, and also because some of these stars were
older than my star I felt that mine, not theirs, ought to be the one to
“go out.”
Among my friends in this country, who helped me in my earlier
efforts to maintain my paper, I may proudly count such men as the
late Hon. Gerrit Smith, and Chief Justice Chase, Hon. Horace Mann,
Hon. Joshua R. Giddings, Hon. Charles Sumner, Hon. John G.
Palfry, Hon. Wm. H. Seward, Rev. Samuel J. May, and many others,
who though of lesser note were equally devoted to my cause.
Among these latter ones were Isaac and Amy Post, William and
Mary Hallowell, Asa and Hulda Anthony, and indeed all the
committee of the Western New York Anti-Slavery Society. They held
festivals and fairs to raise money, and assisted me in every other
possible way to keep my paper in circulation, while I was a non-
voting abolitionist, but withdrew from me when I became a voting
abolitionist. For a time the withdrawal of their coöperation
embarrassed me very much, but soon another class of friends were
raised up for me, chief amongst whom were the Porter family of
Rochester. The late Samuel D. Porter and his wife Susan F. Porter,
and his sisters, Maria and Elmira Porter, deserve grateful mention as
among my steadfast friends, who did much in the way of supplying
pecuniary aid.
Of course there were moral forces operating against me in
Rochester, as well as material ones. There were those who regarded
the publication of a “Negro paper” in that beautiful city as a blemish
and a misfortune. The New York Herald, true to the spirit of the
times, counselled the people of the place to throw my printing press
into Lake Ontario and to banish me to Canada, and while they were
not quite prepared for this violence, it was plain that many of them
did not well relish my presence amongst them. This feeling, however,
wore away gradually, as the people knew more of me and my works.
I lectured every Sunday evening during an entire winter in the
beautiful Corinthian Hall, then owned by Wm. R. Reynolds, Esq.,
who though he was not an abolitionist, was a lover of fair-play and
was willing to allow me to be heard. If in these lectures I did not
make abolitionists I did succeed in making tolerant the moral
atmosphere in Rochester; so much so, indeed, that I came to feel as
much at home there as I had ever done in the most friendly parts of
New England. I had been at work there with my paper but a few
years before colored travelers told me that they felt the influence of
my labors when they came within fifty miles. I did not rely alone upon
what I could do by the paper, but would write all day, then take a
train to Victor, Farmington, Canandaigua, Geneva, Waterloo,
Batavia, or Buffalo, or elsewhere, and speak in the evening,
returning home afterwards or early in the morning, to be again at my
desk writing or mailing papers. There were times when I almost
thought my Boston friends were right in dissuading me from my
newspaper project. But looking back to those nights and days of toil
and thought, compelled often to do work for which I had no
educational preparation, I have come to think that, under the
circumstances it was the best school possible for me. It obliged me
to think and read, it taught me to express my thoughts clearly, and
was perhaps better than any other course I could have adopted.
Besides it made it necessary for me to lean upon myself, and not
upon the heads of our Anti-Slavery church. To be a principal, and not
an agent. I had an audience to speak to every week, and must say
something worth their hearing, or cease to speak altogether. There is
nothing like the lash and sting of necessity to make a man work, and
my paper furnished this motive power. More than one gentleman
from the south, when stopping at Niagara, came to see me, that they
might know for themselves if I could indeed write, having as they
said believed it impossible that an uneducated fugitive slave could
write the articles attributed to me. I found it hard to get credit in some
quarters either for what I wrote or what I said. While there was
nothing very profound or learned in either, the low estimate of Negro
possibilities induced the belief that both my editorials and my
speeches were written by white persons. I doubt if this scepticism
does not still linger in the minds of some of my democratic fellow-
citizens.
The 2d of June, 1872, brought me a very grievous loss. My
house in Rochester was burnt to the ground, and among other things
of value, twelve volumes of my paper, covering the period from 1848
to 1860, were devoured by the flames. I have never been able to
replace them, and the loss is immeasurable. Only a few weeks
before, I had been invited to send these bound volumes to the library
of Harvard University where they would have been preserved in a
fire-proof building, and the result of my procrastination attests the
wisdom of more than one proverb. Outside the years embraced in
the late tremendous war, there has been no period, more pregnant
with great events, or better suited to call out the best mental and
moral energies of men, than that covered by these lost volumes. If I
have at any time said or written that which is worth remembering or
repeating, I must have said such things between the years 1848 and
1860, and my paper was a chronicle of most of what I said during
that time. Within that space we had the great Free Soil Convention at
Buffalo, the Nomination of Martin Van Buren, the Fugitive Slave Law,
the 7th March Speech by Daniel Webster, the Dred Scott decision,
the repeal of the Missouri Compromise, the Kansas Nebraska bill,
the Border war in Kansas, the John Brown raid upon Harper’s Ferry,
and a part of the War against the Rebellion, with much else, well
calculated to fire the souls of men having one spark of Liberty and
Patriotism within them. I have only fragments now, of all the work
accomplished during these twelve years, and must cover this chasm,
as best I can from memory and the incidental items, which I am able
to glean from various sources. Two volumes of the North Star have
been kindly supplied me, by my friend, Marshall Pierce of Saco, Me.
He had these carefully preserved and bound in one cover and sent
to me in Washington. He was one of the most systematically careful
men of all my anti-slavery friends, for I doubt if another entire volume
of the paper exists.
 One important branch of my anti-slavery work in Rochester, in
addition to that of speaking and writing against slavery, must not be
forgotten or omitted. My position gave me the chance of hitting that
old enemy some telling blows, in another direction than these. I was
on the southern border of Lake Ontario, and the Queen’s Dominions
were right over the way—and my prominence as an abolitionist, and
as the editor of an anti-slavery paper, naturally made me the station
master and conductor of the underground railroad passing through
this goodly city. Secrecy and concealment were necessary
conditions to the successful operation of this railroad, and hence its
prefix “underground.” My agency was all the more exciting and
interesting, because not altogether free from danger. I could take no
step in it without exposing myself to fine and imprisonment, for these
were the penalties imposed by the fugitive slave law, for feeding,
harboring, or otherwise assisting a slave to escape from his master;
but in face of this fact, I can say, I never did more congenial,
attractive, fascinating, and satisfactory work. True as a means of
destroying slavery, it was like an attempt to bail out the ocean with a
teaspoon, but the thought that there was one less slave, and one
more freeman,—having myself been a slave, and a fugitive slave—
brought to my heart unspeakable joy. On one occasion I had eleven
fugitives at the same time under my roof, and it was necessary for
them to remain with me, until I could collect sufficient money to get
them on to Canada. It was the largest number I ever had at any one
time, and I had some difficulty in providing so many with food and
shelter, but as may well be imagined, they were not very fastidious in
either direction, and were well content with very plain food, and a
strip of carpet on the floor for a bed, or a place on the straw in the
barn loft.
The underground railroad had many branches; but that one with
which I was connected had its main stations in Baltimore,
Wilmington, Philadelphia, New York, Albany, Syracuse, Rochester,
and St. Catharines (Canada). It is not necessary to tell who were the
principal agents in Baltimore; Thomas Garrett was the agent in
Wilmington; Melloe McKim, William Still, Robert Purvis, Edward M.
Davis, and others did the work in Philadelphia; David Ruggles, Isaac
T. Hopper, Napolian, and others, in New York city; the Misses Mott
and Stephen Myers, were forwarders from Albany; Revs. Samuel J.
May and J. W. Loguen, were the agents in Syracuse; and J. P.
Morris and myself received and dispatched passengers from
Rochester to Canada, where they were received by Rev. Hiram
Wilson. When a party arrived in Rochester, it was the business of Mr.
Morris and myself to raise funds with which to pay their passages to
St. Catharines, and it is due to truth to state, that we seldom called in
vain upon whig or democrat for help. Men were better than their
theology, and truer to humanity, than to their politics, or their offices.
On one occasion while a slave master was in the office of a
United States commissioner, procuring the papers necessary for the
arrest and rendition of three young men who had escaped from
Maryland, (one of whom was under my roof at the time, another at
Farmington, and the other at work on the farm of Asa Anthony just a
little outside the city limits,) the law partner of the commissioner, then
a distinguished democrat, sought me out, and told me what was
going on in his office, and urged me by all means to get these young
men out of the way of their pursuers and claimants. Of course no
time was to be lost. A swift horseman was dispatched to Farmington,
eighteen miles distant, another to Asa Anthony’s farm about three
miles, and another to my house on the south side of the city, and
before the papers could be served, all three of the young men were
on the free waves of Lake Ontario, bound to Canada. In writing to
their old master, they had dated their letter at Rochester, though they
had taken the precaution to send it to Canada to be mailed, but this
blunder in the date had betrayed their whereabouts, so that the
hunters were at once on their tracks.
So numerous were the fugitives passing through Rochester that I
was obliged at last to appeal to my British friends for the means of
sending them on their way, and when Mr. and Mrs. Carpenter and
Mrs. Croffts took the matter in hand, I had never any further trouble
in that respect. When slavery was abolished I wrote to Mrs.
Carpenter, congratulating her that she was relieved of the work of
raising funds for such purposes, and the characteristic reply of that
lady was that she had been very glad to do what she had done, and
had no wish for relief.
 My pathway was not entirely free from thorns in Rochester, and
the wounds and pains inflicted by them were perhaps much less
easily borne, because of my exemption from such annoyances while
in England. Men can in time become accustomed to almost anything,
even to being insulted and ostracised, but such treatment comes
hard at first, and when to some extent unlooked for. The vulgar
prejudice against color, so common to Americans, met me in several
disagreeable forms. A seminary for young ladies and misses, under
the auspices of Miss Tracy, was near my house on Alexander street,
and desirous of having my daughter educated like the daughters of
other men, I applied to Miss Tracy for her admission to her school.
All seemed fair, and the child was duly sent to “Tracy Seminary,” and
I went about my business happy in the thought that she was in the
way of a refined and Christian education. Several weeks elapsed
before I knew how completely I was mistaken. The little girl came
home to me one day and told me she was lonely in that school; that
she was in fact kept in solitary confinement; that she was not allowed
in the room with the other girls, nor to go into the yard when they
went out; that she was kept in a room by herself and not permitted to
be seen or heard by the others. No man with the feeling of a parent
could be less than moved by such a revelation, and I confess that I
was shocked, grieved, and indignant. I went at once to Miss Tracy to
ascertain if what I had heard was true, and was coolly told it was,
and the miserable plea was offered that it would have injured her
school if she had done otherwise. I told her she should have told me
so at the beginning, but I did not believe that any girl in the school
would be opposed to the presence of my daughter, and that I should
be glad to have the question submitted to them. She consented to
this, and to the credit of the young ladies, not one made objection.
Not satisfied with this verdict of the natural and uncorrupted sense of
justice and humanity of these young ladies, Miss Tracy insisted that
the parents must be consulted, and if one of them objected she
should not admit my child to the same apartment and privileges of
the other pupils. One parent only had the cruelty to object, and he
was Mr. Horatio G. Warner, a democratic editor, and upon his
adverse conclusion, my daughter was excluded from “Tracy
Seminary.” Of course Miss Tracy was a devout Christian lady after
the fashion of the time and locality, in good and regular standing in
the church.
My troubles attending the education of my children were not to
end here. They were not allowed in the public school in the district in
which I lived, owned property, and paid taxes, but were compelled, if
they went to a public school, to go over to the other side of the city,
to an inferior colored school. I hardly need say that I was not
prepared to submit tamely to this proscription, any more than I had
been to submit to slavery, so I had them taught at home for a while,
by Miss Thayer. Meanwhile I went to the people with the question
and created considerable agitation. I sought and obtained a hearing
before the Board of Education, and after repeated efforts with voice
and pen, the doors of the public schools were opened and colored
children were permitted to attend them in common with others.
There were barriers erected against colored people in most other
places of instruction and amusements in the city, and until I went
there they were imposed without any apparent sense of injustice or
wrong, and submitted to in silence; but one by one they have
gradually been removed and colored people now enter freely all
places of public resort without hindrance or observation. This change
has not been wholly effected by me. From the first I was cheered on
and supported in my demands for equal rights by such respectable
citizens as Isaac Post, Wm. Hallowell, Samuel D. Porter, Wm. C.
Bloss, Benj. Fish, Asa Anthony, and many other good and true men
of Rochester.
Notwithstanding what I have said of the adverse feeling exhibited
by some of its citizens at my selection of Rochester as the place to
establish my paper, and the trouble in educational matters just
referred to, that selection was in many respects very fortunate. The
city was, and still is, the center of a virtuous, intelligent, enterprising,
liberal, and growing population. The surrounding country is
remarkable for its fertility; and the city itself possesses one of the
finest water-powers in the world. It is on the line of the New York
Central railroad—a line that with its connections, spans the whole
country. Its people were industrious and in comfortable
circumstances; not so rich as to be indifferent to the claims of
humanity, and not so poor as to be unable to help any good cause
which commanded the approval of their judgment.
The ground had been measurably prepared for me by the labors
of others—notably by Hon. Myron Holley, whose monument of
enduring marble now stands in the beautiful cemetery at Mount
Hope, upon an eminence befitting his noble character. I know of no
place in the Union where I could have located at the time with less
resistance, or received a larger measure of sympathy and
coöperation, and I now look back to my life and labors there with
unalloyed satisfaction, and having spent a quarter of a century
among its people, I shall always feel more at home there than any
where else in this country.

Portrait of John Brown.

 CHAPTER VIII.
JOHN BROWN AND MRS. STOWE.

My First Meeting with Capt. John Brown—The Free Soil Movement—Colored

Convention—Uncle Tom’s Cabin—Industrial School for Colored People—
Letter to Mrs. H. B. Stowe.

ABOUT the time I began my enterprise in Rochester I chanced to

spend a night and a day under the roof of a man whose character
and conversation, and whose objects and aims in life made a very
deep impression upon my mind and heart. His name had been
mentioned to me by several prominent colored men, among whom
were the Rev. Henry Highland Garnet and J. W. Loguen. In speaking
of him their voices would drop to a whisper, and what they said of
him made me very eager to see and know him. Fortunately I was
invited to see him in his own house. At the time to which I now refer
this man was a respectable merchant in a populous and thriving city,
and our first place of meeting was at his store. This was a substantial
brick building, on a prominent, busy street. A glance at the interior,
as well as at the massive walls without, gave me the impression that
the owner must be a man of considerable wealth. From this store I
was conducted to his house, where I was kindly received as an
expected guest. My welcome was all I could have asked. Every
member of the family, young and old, seemed glad to see me, and I
was made much at home in a very little while. I was, however, a little
disappointed with the appearance of the house and with its location.
After seeing the fine store I was prepared to see a fine residence, in
an eligible locality, but this conclusion was completely dispelled by
actual observation. In fact, the house was neither commodious nor
elegant, nor its situation desirable. It was a small wooden building,
on a back street, in a neighborhood chiefly occupied by laboring men
and mechanics; respectable enough to be sure, but not quite the
place, I thought, where one would look for the residence of a
flourishing and successful merchant. Plain as was the outside of this
man’s house, the inside was plainer. Its furniture would have
satisfied a Spartan. It would take longer to tell what was not in this
house than what was in it. There was an air of plainness about it
which almost suggested destitution. My first meal passed under the
misnomer of tea, though there was nothing about it resembling the
usual significance of that term. It consisted of beef soup, cabbage,
and potatoes; a meal such as a man might relish after following the
plow all day, or performing a forced march of a dozen miles over a
rough road in frosty weather. Innocent of paint, veneering, varnish, or
table-cloth, the table announced itself unmistakably of pine and of
the plainest workmanship. There was no hired help visible. The
mother, daughters, and sons did the serving and did it well. They
were evidently used to it, and had no thought of any impropriety or
degradation in being their own servants. It is said that a house in
some measure reflects the character of its occupants; this one
certainly did. In it there were no disguises, no illusions, no make
believes. Everything implied stern truth, solid purpose, and rigid
economy. I was not long in company with the master of this house
before I discovered that he was indeed the master of it, and was
likely to become mine too if I stayed long enough with him. He
fulfilled St. Paul’s idea of the head of the family. His wife believed in
him, and his children observed him with reverence. Whenever he
spoke his words commanded earnest attention. His arguments,
which I ventured at some points to oppose, seemed to convince all;
his appeals touched all, and his will impressed all. Certainly I never
felt myself in the presence of a stronger religious influence than
while in this man’s house.
In person he was lean, strong, and sinewy, of the best New
England mould, built for times of trouble, fitted to grapple with the
flintiest hardships. Clad in plain American woolen, shod in boots of
cowhide leather, and wearing a cravat of the same substantial
material, under six feet high, less than 150 pounds in weight, aged
about fifty, he presented a figure, straight and symmetrical as a
mountain pine. His bearing was singularly impressive. His head was
not large, but compact and high. His hair was coarse, strong, slightly
gray and closely trimmed, and grew low on his forehead. His face
was smoothly shaved, and revealed a strong square mouth,
supported by a broad and prominent chin. His eyes were bluish gray,
and in conversation they were full of light and fire. When on the
street, he moved with a long, springing race horse step, absorbed by
his own reflections, neither seeking or shunning observation. Such
was the man, whose name I had heard in whispers, such was the
spirit of his house and family, such was the house in which he lived,
and such was Captain John Brown, whose name has now passed
into history, as one of the most marked characters, and greatest
heroes known to American fame.
After the strong meal already described, Captain Brown
cautiously approached the subject which he wished to bring to my
attention; for he seemed to apprehend opposition to his views. He
denounced slavery in look and language fierce and bitter, thought
that slaveholders had forfeited their right to live, that the slaves had
the right to gain their liberty in any way they could, did not believe
that moral suasion would ever liberate the slave, or that political
action would abolish the system. He said that he had long had a plan
which could accomplish this end, and he had invited me to his house
to lay that plan before me. He said he had been for some time
looking for colored men to whom he could safely reveal his secret,
and at times he had almost despaired of finding such men, but that
now he was encouraged, for he saw heads of such rising up in all
directions. He had observed my course at home and abroad, and he
wanted my coöperation. His plan as it then lay in his mind, had much
to commend it. It did not, as some suppose, contemplate a general
rising among the slaves, and a general slaughter of the slave
masters. An insurrection he thought would only defeat the object, but
his plan did contemplate the creating of an armed force which should
act in the very heart of the south. He was not averse to the shedding
of blood, and thought the practice of carrying arms would be a good
one for the colored people to adopt, as it would give them a sense of
their manhood. No people he said could have self respect, or be
respected, who would not fight for their freedom. He called my
attention to a map of the United States, and pointed out to me the
far-reaching Alleghanies, which stretch away from the borders of
New York, into the Southern States. “These mountains,” he said, “are
the basis of my plan. God has given the strength of the hills to
freedom, they were placed here for the emancipation of the negro
race; they are full of natural forts, where one man for defense will be
equal to a hundred for attack; they are full also of good hiding
places, where large numbers of brave men could be concealed, and
baffle and elude pursuit for a long time. I know these mountains well,
and could take a body of men into them and keep them there despite
of all the efforts of Virginia to dislodge them. The true object to be
sought is first of all to destroy the money value of slave property; and
that can only be done by rendering such property insecure. My plan
then is to take at first about twenty-five picked men, and begin on a
small scale; supply them arms and ammunition, post them in squads
of fives on a line of twenty-five miles, the most persuasive and
judicious of whom shall go down to the fields from time to time, as
opportunity offers, and induce the slaves to join them, seeking and
selecting the most restless and daring.”
He saw that in this part of the work the utmost care must be
used to avoid treachery and disclosure. Only the most conscientious
and skillful should be sent on this perilous duty; with care and
enterprise he thought he could soon gather a force of one hundred
hardy men, men who would be content to lead the free and
adventurous life to which he proposed to train them, when these
were properly drilled, and each man had found the place for which
he was best suited, they would begin work in earnest; they would run
off the slaves in large numbers, retain the brave and strong ones in
the mountains, and send the weak and timid to the north by the
underground railroad; his operations would be enlarged with
increasing numbers, and would not be confined to one locality.
When I asked him, how he would support these men? he said
emphatically, he would subsist them upon the enemy. Slavery was a
state of war, and the slave had a right to anything necessary to his
freedom. But said I, “suppose you succeed in running off a few
slaves, and thus impress the Virginia slaveholder with a sense of
insecurity in their slaves, the effect will be only to make them sell
their slaves further south.” “That,” said he, “will be first what I want to
do; then I would follow them up. If we could drive slavery out of one
county, it would be a great gain; it would weaken the system
throughout the state.” “But they would employ bloodhounds to hunt
you out of the mountains.” “That they might attempt,” said he, “but
the chances are, we should whip them, and when we should have
whipt one squad, they would be careful how they pursued.” “But you
might be surrounded and cut off from your provisions or means of
subsistence.” He thought that could not be done so they could not
cut their way out, but even if the worst came, he could but be killed,
and he had no better use for his life than to lay it down in the cause
of the slave. When I suggested that we might convert the
slaveholders, he became much excited, and said that could never
be, “he knew their proud hearts and that they would never be
induced to give up their slaves, until they felt a big stick about their
heads.” He observed that I might have noticed the simple manner in
which he lived, adding that he had adopted this method in order to
save money to carry out his purposes. This was said in no boastful
tone, for he felt that he had delayed already too long and had no
room to boast either his zeal or his self denial. Had some men made
such display of rigid virtue, I should have rejected it, as affected,
false and hypocritical, but in John Brown, I felt it to be real as iron or
granite. From this night spent with John Brown in Springfield, Mass.,
1847, while I continued to write and speak against slavery, I became
all the same less hopeful of its peaceful abolition. My utterances
became more and more tinged by the color of this man’s strong
impressions. Speaking at an anti-slavery convention in Salem, Ohio,
I expressed this apprehension that slavery could only be destroyed
by bloodshed, when I was suddenly and sharply interrupted by my
good old friend Sojourner Truth with the question, “Frederick, is God
dead?” “No.” I answered, and “because God is not dead slavery can
only end in blood.” My quaint old sister was of the Garrison school of
non-resistants, and was shocked at my sanguinary doctrine, but she
too became an advocate of the sword, when the war for the
maintenance of the Union was declared.
In 1848 it was my privilege to attend, and in some measure to
participate in the famous Free-Soil Convention held in Buffalo, New