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Nursing Care of
the Pediatric
Neurosurgery Patient
Third Edition
Cathy C. Cartwright
Donna C. Wallace
Editors
123
Nursing Care of the Pediatric
Neurosurgery Patient
Cathy C. Cartwright • Donna C. Wallace
Editors
Nursing Care of the

Pediatric Neurosurgery
Patient
Third Edition
Editors
Cathy C. Cartwright Donna C. Wallace
Childrens Mercy Hospital Division of Pediatric Neurosurgery
Kansas City Banner Children Specialists at Cardon
Missouri Children’s Medical Center
USA Mesa
Arizona
USA
ISBN 978-3-319-49318-3 ISBN 978-3-319-49319-0 (eBook)

DOI 10.1007/978-3-319-49319-0
Library of Congress Control Number: 2017938118
© Springer International Publishing AG 2017

© Springer-Verlag Berlin Heidelberg 2007, 2013
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Printed on acid-free paper
This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword
Caring for the pediatric patient requires nurses who understand the specific
challenges and possess specialized knowledge. A solid knowledge base of not
only disease states but also developmental milestones is critical in the deliv-
ery of care to these young patients and their families. With contributors from
across the USA and Canada, Cathy C. Cartwright and Donna Wallace have
once again provided us their expertise in this latest edition of the textbook
Nursing Care of the Pediatric Neurosurgery Patient.
In addition to the 12 chapters in the previous edition that covered assess-
ment, development anomalies, injury, and disease entities, the editors have
added four new chapters: “Neuroimaging,” “Skull Anomalies,” “Abusive
Head Trauma,” and lastly “Pediatric Athletic Concussion” which has become
a hot topic in recent years. The authors and editors have captured the com-
plexity of pediatric patient care and added excellent figures and case studies
to create a text that meets the needs of not only nurses but all healthcare
providers.
As a neuroscience clinical nurse specialist, mother, and now grandmother,
I have thumbed and pored over my previous edition of this invaluable book
often, and it made a significant contribution to shaping my knowledge. I
know this new edition will add even more, and I hope that every neuroscience
nurse will have their own copy and use it as often as I have done to reference
pediatric care wherever it is needed.
AANN Past President
inda R. Littlejohns, MSN, RN, CNRN, SCRN, FAAN

L
San Juan Capistrano, California
v
Preface
We are so pleased that Springer requested a third edition of “the book”! With
improvements in each successive edition, we have tried to remain true to our
original intent: to provide a reference for nurses who care for children with
neurosurgical conditions. Thus, we are also pleased that it will be available
online to nurses worldwide.
This edition has been expanded to include four new chapters. Common
and unusual lumps and bumps found on the head are discussed in the chapter
on skull and scalp anomalies. The increasing concern over abusive head
trauma and pediatric athletic concussion warrants that those topics have their
own separate chapters. And a basic knowledge of neuroimaging is key in
helping the nurse understand their patient’s condition and can be instrumental
when explaining that condition to parents.
None of this would be possible without the fine work of the authors who
have taken the time to share their expertise. Many thanks to them for their
contributions – some participating for the second or third time and some for
the first. As always, we thank the families who have allowed us to be part of
their lives during the times when they are most vulnerable. It is our hope that
neurosurgery nurses use this book as a resource as they support these families
on their journey.
Kansas City, MO, USA Cathy C. Cartwright

Mesa, AZ, USA Donna C. Wallace
2017
vii
Acknowledgments
I wish to acknowledge the American Association of Neuroscience Nurses

(AANN) for providing opportunities for my professional development and
Linda Littlejohns for her support throughout my neuroscience career.
Especially Zach for his editorial efforts and being my partner in all things.
Cathy C. Cartwright
I wish to acknowledge and offer gratitude and thanks to family and friends
who are ever supportive of this project. This book could not have been pos-
sible without the encouragement of neuroscience nursing colleagues and
mentors, those bright people that I wanted to be like early in my career, those
who said the right thing when it needed to be said, and those who always
believed in me when the road became bumpy.
Donna C. Wallace
ix
Contents
1 Neurological Assessment of the Neonate,

Infant, Child, and Adolescent �� 1
Jennifer A. Disabato and Dee A. Daniels
2 Hydrocephalus�� 39
Nadine Nielsen and Amanda Breedt
3 Craniosynostosis and Plagiocephaly�� 91
Cathy C. Cartwright and Patricia D. Chibbaro
4 Skull and Scalp Anomalies�� 133
Donna C. Wallace and Lindsey N.Weak
5 Neural Tube Defects�� 151
Mary L. Dexter and Teresa Schultz
6 Chiari Malformation and Syringomyelia�� 177
Ambre’ L. Pownall
7 Tumors of the Central Nervous System �� 195
Stephanie Smith
8 Traumatic Brain Injury�� 255
Angela Hoersting and Jodi E. Mullen
9 Pediatric Athletic Concussion �� 317
Jill Kouts and Tanya Filardi
10 Abusive Head Trauma �� 335
Jodi E. Mullen
11 Spine�� 351
Anne Stuedemann and Valorie Thomas
12 Neurovascular Disease�� 395
Theresa M. Gabay and Davonna Ledet
13 Surgical Management of Epilepsy�� 457
Patti L. Batchelder
14 Surgical Management of Functional Disorders�� 493
Herta Yu
xi
xii Contents
15 Infections of the Central Nervous System�� 515

Gina Weddle
16 Perioperative Care �� 529
Sarah M. Lagergren and Gail C. Dustman
17 Transition from Pediatric to Adult Care�� 555
Theresa M. Gabay, Jennifer A. Disabato, and Teresa Schultz
18 Neuroimaging �� 573
Angela Forbes
Index�� 597
Neurological Assessment
of the Neonate, Infant, Child,
1
and Adolescent
Jennifer A. Disabato and Dee A. Daniels
1.1 Introduction secondary complications that can further impede

recovery from a neurological disease or traumatic
1.1.1 I mportance of Neurological injury. Potential complications include the inabil-
Assessment ity to protect the airway leading to aspiration,
immobility leading to venous stasis and throm-
Serial, consistent, and well-documented neuro- bosis, endocrine disorders related to central hor-
logical assessments are the most important aspect monal regulation, impaired communication, and
of nursing care for the pediatric neurosurgical behavioral issues, among others (Hickey 2009).
patient. A bedside nurse is often the first to note a It is understood that children are not always
subtle change in a child’s level of responsiveness, under the care and custody of their parents. As
pattern of movement, or signs and symptoms used in this book, however, the term “parent(s)”
of decline in neurological function. Both keen is intended to include family members who have
observation skills and knowledge of the patient’s custody of a child, foster parents, guardians, and
baseline neurological function are essential tools other primary caregivers.
for the pediatric neurosurgical nurse. Rapid
response and escalation of care in response to
changes in assessment are necessary to prevent 1.1.2 Nursing Approach
to the Pediatric Neurological
Assessment
J.A. Disabato, DNP, CPNP-PC, AC (*)
Department of Child Neurology, Neurological assessment should be an integral
Children’s Hospital Colorado, Aurora, CO, USA
part of the entire physical assessment, and aspects
University of Colorado College of Nursing, can be integrated into the general exam of patients
13120 E. 19th Avenue, 4126,
in both inpatient and outpatient settings. The
Aurora, CO 80045, USA
e-mail: [email protected] approach to neurological assessment should be
systematic and includes pertinent health history,
D.A. Daniels, MS, RN, CPNP
Department of Pediatrics, e.g., coexisting conditions, developmental status
Sie Center for Down Syndrome, of the child, the nature and extent of the injury or
Children’s Hospital Colorado, surgery performed, and potential complications
University of Colorado School of Medicine,
13123 East 16th Ave, B-745,
(Amidei et al. 2010). Sources of this information
Aurora, CO 80045, USA are broad and include the verbal report provided
e-mail: [email protected] in care transitions, the medical record, the parent
© Springer International Publishing AG 2017 1

C.C. Cartwright, D.C. Wallace (eds.), Nursing Care of the Pediatric Neurosurgery Patient,
DOI 10.1007/978-3-319-49319-0_1
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2 J.A. Disabato and D.A. Daniels
caregiver, and the nursing and medical col- sedation for diagnostic imaging, and the speed of
leagues, including the neurosurgeon, neurologist, imaging has increased substantially in recent
and other health-care providers. years.
Knowledge of physical and developmental Advancements in imaging techniques make it
disorders not directly associated with the neuro- easier to consider repeat studies as treatment or
logical condition, such as renal, cardiac, or pul- recovery progresses, so that changes can be mon-
monary status, is important to a comprehensive itored through comparisons to the baseline imag-
approach and enhancing the patient’s outcome. ing. However, the use of diagnostic testing in an
Care planning should be a team approach that era of health-care reform calls for all involved to
involves the parents and the multidisciplinary consider the costs associated with a test and
team to assure optimal communication of key query whether the results will truly change the
information, and avoid unnecessary repetition of plan or outcome for the patient.
tests, or oversight of important clinical findings. In general, radiographic or digital imaging
Factors that impact the nurse assessment of (such as MRI) are tools to evaluate the struc-
the child will be the age and developmental stage ture of the brain and spinal cord, while other
of the child. The history should include antenatal, diagnostic tests like EEG, SPECT scanning,
perinatal, and postnatal information as well as nuclear medicine scans, and Wada test (intrac-
developmental milestones (Sables-Baus and arotid sodium amobarbital procedure to later-
Robinson 2011). Other factors include the nature alize language and memory) are evaluating
of the child’s diagnosis (chronic, acute, static, specific functions of the brain. PET scans look
progressive), the setting in which the assessment at metabolic function and utilization of glucose
takes place (critical care unit, general care are, by the brain. Some tests serve both diagnostic
outpatient clinic, school nurse office), and the and therapeutic outcomes (Hedlund 2002).
information available at the time of the assess- Magnetoencephalography (MEG) or magnetic
ment from other members of the multidisci- source imaging (MSI) and functional MRIs
plinary team. Family dynamics and social (fMRI) are methods of localizing areas of abnor-
circumstances can also impact the nurses’ mality associated with ictal (seizure) onset
approach to the assessment. (Knowlton 2008). Newer technologies allow for
evaluation of cerebral blood flow and brain perfu-
sion. Three methods currently in use for monitor-
1.1.3 Diagnostic Imaging ing cerebral ischemia include Doppler ultrasound,
and Testing in Neurological near-infrared spectroscopy (NIRS), and
Assessment amplitude-integrated electroencephalogram
(aEEG) (Greisen 2006; Iaia and Barker 2008).
Diagnostic imaging and other laboratory and Table 1.1 is a listing of the most common neuro-
electrical testing of the nervous system play an logical diagnostic tests and imaging modalities
important role in understanding the nature of used in pediatrics.
neurological disorders. The brain, spinal cord,
and peripheral neurological system are organs of
both intricate structure and complex metabolic, 1.2 Developmental Assessment:
vascular, and cellular function. Diagnostic tools Growth and Developmental
are generally focused on one aspect of the struc- Tasks by Age
ture or function, but several tests incorporated
with a neurological assessment of the child are Knowledge of human growth parameters and
often the key to an accurate diagnosis and appro- normal developmental landmarks is critical to the
priate treatment. Ongoing advances in medicine, assessment of each age group. The Individuals
technology, and pharmacology have contributed with Disabilities Education Act (IDEA)
to safer outcomes for children who may need Amendments of 1997 (U.S. Department of
1 Neurological Assessment of the Neonate, Infant, Child, and Adolescent 3
Table 1.1 Neurological diagnostic and imaging modalities

Diagnostic or imaging modality Technology utilized Nursing and patient considerations
X-rays of the skull and vertebral X-rays to look at boney structures of Patient should be immobilized in a collar
column the skull and spine, fractures, integrity for transport if there is a question of
of the spinal column, and the presence spinal fracture
of calcium intracranially
Cranial ultrasound Doppler sound waves to image through No sedation or intravenous access
soft tissue. In infants it can only be needed. Used to follow ventricle size/
used if fontanel is open bleeding in neonates/infants
Computerized tomography Differentiates tissues by density Noninvasive unless contrast is used or
with/without contrast relative to water with computer sedation needed. Complications include
averaging and mathematical reaction to contrast material or
reconstruction of absorption coefficient extravasation at injection site
measurements
Computerized tomography – Same as above with software No changes in study for patient. Used for
bone windows and/or three- capabilities to subtract intracranial complex skull and vertebral anomalies to
dimensional reconstruction contents to look specifically at the bone guide surgical decision-making
and reconstruct the skull or vertebral
column in a three-dimensional model
Cerebral angiography Intra-arterial injection of contrast Done under deep sedation or anesthesia;
medium to visualize blood vessels; local reaction or hematoma may occur;
transfemoral approach most common; systemic reactions to contrast or
occasionally brachial or direct carotid dysrhythmias; transient ischemia or
is used vasospasm; patient needs to lie flat after
and CMS checks of extremity where
injection was done are required
MRI with or without contrast Differentiates tissues by their response No radiation exposure; screened prior to
(gadolinium) to radio-frequency pulses in a magnetic study for indwelling metal, pacemakers,
field; used to visualize structures near braces, electronic implants; sedation
bone, infarction, demyelination, and required for young children because of
cortical dysplasias sounds and claustrophobia; contrast risks
include allergic reaction and injection site
extravasation
MRA Same technology as above used to In some cases it can replace the need for
MRV study flow in vessels; radio-frequency cerebral angiography; new technologies
signals emitted by moving protons can are making this less invasive study more
be manipulated to create the image of useful in children with vascular
vascular contrast abnormalities
Functional MRI Technique for imaging activity of the Used in patients who are potential
brain using rapid scanning to detect candidates for epilepsy surgery to
changes in oxygen consumption of the determine areas of cortical abnormality
brain; changes can reflect increased and their relationship to important cortex
activity in certain cells responsible for motor and speech
functions
Physiologic imaging techniques – nuclear medicine imaging
SPECT Nuclear medicine study utilizing Often used in epilepsy patients to
injection of isotopes and imaging of the diagnose areas of cerebral uptake during
brain to determine if there is increased a seizure (ictal SPECT) or between
activity in an area of abnormality; seizures (intraictal SPECT)
three-dimensional measurements of
regional blood flow
SISCOM Utilizing the technology of SPECT No significant difference for patient;
with MRI to look at areas of increased software as well as expertise of
uptake in conjunction with MRI images radiologist is used to evaluate study
of the cortex and cortical surface
(continued)
Table 1.1 (continued)

Diagnostic or imaging modality Technology utilized Nursing and patient considerations
PET Nuclear medicine study that assesses Patient should avoid chemicals that
perfusion and level of metabolic depress or stimulate the CNS and alter
activity of both glucose and oxygen in glucose metabolism (e.g., caffeine);
the brain; radiopharmaceuticals are patient may be asked to perform certain
injected for the study tasks during study
Electrical studies
EEG Records gross electrical activity across Success of study dependent on placement
Routine surface of the brain; ambulatory EEG and stability of electrodes and ability to
Ambulatory used may be used for 24–48 h with keep them on in children; routine studies
data downloaded after study; video often miss actual seizures but background
Video
combines EEG recording with activity can be useful information
simultaneous videotaping
Evoked responses Measure electrical activity in specific Results can vary depending on body size,
SSER sensory pathways in response to age, and characteristics of stimuli;
VER external stimuli; signal average sensation for each test will be different
produces waveforms that have for patient – auditory clicks (BAER),
BAER
anatomic correlates according to the strobe light (VER), or electrical current
latency of wave peaks on the skin – somatosensory (SSER)
MEG Noninvasive functional brain imaging Patients will need to remove all metals
(magnetoencephalography) that uses electrodes on the scalp to prior to entry into the room. Pacemakers
mapping measure tiny changes in magnetic or vagus nerve stimulators (VNS) will
fields between groups of neurons and cause artifact. VNS should be turned off
projects them onto MRI brain imaging prior to the study and any magnetic field
for correlation. Used to assist can affect the function of the VNS
in localization of seizure foci in
evaluation of patients for epilepsy
surgery and to determine the language
dominant hemisphere
MSI (magnetic source imaging) Using a weak magnetic field, images
normal and abnormal electrical activity
and produces clear images. Messages
are sent to the brain via small
stimulators on lips and fingers of the
patient and measured and recorded as
electrical activity
aEEG (amplitude-integrated Filtered and compressed EEG data Used primarily in neonates to predict
EEG) used to evaluate long-term trends in neurological outcome following perinatal
background patterns asphyxia
Cerebral perfusion studies
Near-infrared spectroscopy Using light, monitors changes in
(NIRS) cerebral tissue oxygenation through
functional measurements of differential
absorption of hemoglobin at multiple
wave lengths
Transcranial Doppler (TCD) A noninvasive method of monitoring Results indicating low flow velocities
ultrasound cerebral circulation (flow velocity) over after head injury are consistent with low
the middle, anterior and posterior cerebral blood flow, high ICP levels, and
cerebral, ophthalmic, and carotid a poor prognosis
arteries
Adapted from Iaia and Barker (2008)
MRI magnetic resonance imaging, MRA magnetic resonance angiography, MRV magnetic resonance venography,
SPECT single photon emission computerized tomography, SISCOM subtracted ictal spectroscopy co-registered with
MRI, PET positron emission tomography, EEG electroencephalogram, SSER somatosensory evoked potentials, VEP
visual evoked potentials, BAER brainstem auditory evoked potentials, CNS central nervous system
Education Special Education and Rehabilitative the parents’ head circumference, as large heads
Services 2005) mandates the “early identification can be familial.
of, and intervention for developmental disabili- Voluntary motor skills generally develop in a
ties through the development of community- cephalocaudal and proximodistal progression, as
based systems.” This law requires physicians to it parallels the process of myelination. Myelin is
refer children with suspect developmental delays a phospholipid layer that surrounds the axons of
to appropriate intervention services in a timely many neurons, which regulate the speed of trans-
manner. Early identification and intervention can mission. First the head, then the trunk, arms,
have significant impact on later developmental hands, pelvis, legs, bowel, and bladder are
outcomes (Hamilton 2006). brought under voluntary control. Early in life
Development is the essential distinguishing motor activity is largely reflexive, and general-
feature of pediatric nursing. Normal development ized movements predominate. Patterns emerge
is a function of the integrity and maturation of the from the general to the specific; for example, a
nervous system. Only with a working knowledge newborn’s total body response to a stimulus is
of age-related developmental standards can the contrasted with the older child, who responds
examiner be sensitive to the deviations that indi- through simply a smile or words. So as the neuro-
cate slight or early impairment of development muscular system matures, movement gradually
and an abnormal neurological assessment. An becomes more purposeful and coordinated
abnormality in development from birth suggests (Schultz and Hockenberry 2011). The sequence
an intrauterine or perinatal cause. Slowing of the of development is the same for all children, but
rate of acquisition of skills later in infancy or the rate of development varies from child to child.
childhood may imply an acquired abnormality of Finally, as important to a complete neurologi-
the nervous system or metabolic disease. A loss cal exam is an assessment of the child’s cognitive
of skills (regression) over time strongly suggests and emotional development. These abilities
an underlying degenerative disease of the central impact directly on expectations of the child’s
nervous system (Volpe 2009). behavioral, social, and functional capabilities.
Serial measurements can indicate the normal or The younger the child, the more developmental
abnormal dynamics of the child’s growth. One key history is needed from the parents. Accurate
growth measurement important to the neurologi- identification of the child’s mastery of cognitive
cal assessment of the child is the head circumfer- and emotional developmental milestones, as it
ence. The measurement is taken around the most relates to chronological age, is necessary for a
prominent frontal and occipital bones that which comprehensive neurological assessment. It is
offers the maximal circumference. How rapidly imperative to note if the child is making steady
the head circumference accelerates or decelerates developmental progress or has experienced
away from the percentile curve can determine if regression. If regression has occurred, then it is
the underlying cause of the growth change is more important to note the onset of regression.
benign or serious. An example of a benign finding Documenting examples of regression and the
is the presence of extra-axial fluid collections of temporal relationship to current symptoms gives
infancy, which often present with an accelerating further context that may influence the evaluation,
head circumference. Generally, the infant with this diagnosis, and subsequent treatment plan. If the
finding is observed over time, but no intervention child had significant regression in speech at
is warranted. On the other hand, an accelerating 18 months of age followed by seizure onset at
head circumference can also be a sign of increas- 3 years of age, this knowledge may lead to fur-
ing intracranial pressure in uncompensated hydro- ther consideration of autism spectrum disorder
cephalus, which would require immediate rather than simply a seizure disorder. This history
evaluation and treatment. A child with a large head is imperative in planning a comprehensive
in the setting of normal development and normal evaluation and future treatment plan that would
neurologic exam could be explained by measuring span many health-care disciplines.
1.2.1 Developmental Assessment prehensive developmental approach in the hospi-

Tools tal or outpatient setting is to determine the most
appropriate developmentally based neurosurgical
With the diagnosis of a neurosurgical condition care for the patient. Treatment for identified
comes the awareness of potential or realized needs can be better directed toward the develop-
developmental delays. A comprehensive mental age of the child that, if different from the
approach to assessment with a family history, chronological age, will impact the assessment
developmental observations, comprehensive neu- and patient care of the child. This developmental
rological assessment, and developmental screen- information can guide the nurse in planning for
ing is indicated. Selected screening tools can aid the child’s home care, including targeted
in identification of developmental disorders resources such as early intervention services,
defined by prevalence (Rydz 2004). adapted educational plans, and rehabilitation and
Spencer and Daniels (2015) stress the impor- therapy services.
tance of developmental screening with docu-
mented developmental surveillance at each
encounter. An important part of this assessment is 1.2.2 Neonate
the use of parent-report developmental screening
tools. Refer to Table 1.2 adapted by Spencer and Aside from head shape and size and assessment
Daniels (2015) from Rydz (2004) to review cur- of fontanels, there are other aspects unique to the
rently used evidence-based tools. This table is a neurological exam of the neonate and/or infant.
useful reference for finding the most appropriate These are important to understanding the integ-
screening tool for identifying a developmental rity of the nervous system early in life and are
delay in a young child, so that referral can be detailed in this section. The proportional changes
made for further evaluation by a specialist, and in head and body growth from fetal life to adult-
early intervention can occur. The goal of a com- hood are depicted in Fig. 1.1 (Santrock 1998).
Table 1.2 Comparison of commonly used parent-report developmental screening tools (Spencer and Daniels 2016)
Developmental areas Sensitivity and Language
Instrument Age appropriate screened specificity availability
Ages and Stages 3–66 months Global communication, Sensitivity 71–86% English
Questionnaires (3rd Ed.) gross and fine motor, Specificity 90–98% Spanish
ASQ-3 problem-solving, personal-
social, autonomy, affect
Modified Checklist for 18–60 months Screens for autism spectrum Sensitivity 90% English
Autism in Toddlers disorder Specificity 99% Spanish
(M-CHAT) Others
Infant-Toddler Checklist 6–24 months Language, social and Sensitivity 78% English
for Language and communication Specificity 84% Spanish
Communication Others
Parents’ Evaluation of Birth to 8 years Global: fine motor, gross Sensitivity 70–94% English
Developmental Status motor, self-help, expressive Specificity 77–93% Spanish
(PEDS) language, receptive language Vietnamese
and social-emotional Others
Parents’ Evaluation of Birth to 8 years Global: fine/gross motor, Sensitivity 75–87% English
Developmental Status self-help, academics, Specificity 71–88% Spanish
Developmental Milestones expressive/receptive Vietnamese
(PEDS:DM) language, social-emotional Others
Child Development 18 months to Social, self-help, gross Sensitivity 88% English
Review: Parent kindergarten motor, fine motor, language Specificity 88% Spanish
Questionnaires (CDR-PQ) Vietnamese
Fig. 1.1 Changes in proportions of the human body during growth (Santrock 1998)
1.2.2.1 M aternal and Pregnancy/Labor range from 34 to 36 cm within the 25–75% ranges.
and Delivery History Neonates outside this range should be accurately
An interview with the biological mother, or plotted on the appropriate growth chart and seri-
another familiar with the pregnancy, should ally measured (Nellhaus 1968). Further examina-
include questions about any maternal illness, tion of the neonate’s head for a patent fontanel,
nutrition status, drug and/or alcohol use, chronic tautness, and approximation of cranial sutures is
diseases, and any medications taken routinely, vital. Fontanels are best palpated when the neonate
including prescription, over-the-counter, and is in the upright position and not crying. The cra-
herbal supplements. Important factors to know nial sutures should be well approximated, espe-
about the delivery include the administration of cially the coronal, squamosal, and lambdoid
anesthesia or drugs and difficulties with the deliv- sutures, and should not admit a fingertip. The sag-
ery like the need for forceps or vacuum devices. ittal suture may be wider in normal newborns,
Note the infant’s Apgar scores. A need for sup- especially if the baby is premature. A soft, flat, or
plemental oxygen, intubation/ventilation, glucose, sunken anterior and posterior fontanel should be
and abnormalities of bilirubin levels is also impor- palpated. The posterior fontanel may be palpated
tant. A history of post-birth infections, a need for up to 4 weeks of age. More detailed information
medication/oxygen, feeding difficulties, and/or and illustrations regarding cranial sutures and
seizures may also indicate underlying problems. related abnormalities can be found in Chapter 3.
Spine assessments include evaluation for
1.2.2.2 Physical Appearance abnormal midline lumps, dimples, tufts of hair on
The neonatal period is defined as the first 4 weeks the spine, and palpation for vertebral anomalies.
of life. The neonate may be term or premature, and Skin markings such as petechiae, hemangiomas,
the physical characteristics of neonates vary with and hypopigmented or hyperpigmented lesions
their gestational age. Inspection of the shape, sym- may be present at birth and indicative of neuro-
metry, and mobility of the head of the neonate is logical congenital conditions. It is important to
critical for evaluating cranial abnormalities or soft note the size, location, and number of hypo- or
tissue injuries. Head circumference at term will hyperpigmented lesions. In addition, congenital
anomalies of the heart, lungs, and gastrointestinal normal finding (Kramer et al. 1994; Shuper et al.
tract may suggest abnormalities of brain develop- 1991).
ment. However, optic or facial dysmorphisms Strength is assessed by observing the new-
more accurately predict a brain anomaly born’s spontaneous and evoked movements and
(American Academy of Pediatrics 1996). Some by eliciting specific newborn reflexes. Neonates
facial dysmorphisms to note include hyper- or with neuromuscular conditions may manifest
hypotelorism, flat philtrum, thin upper lip, epi- with abnormally low muscle tone (hypotonia),
canthic folds, unequal size of the eyes, nystag- paradoxical breathing, hip dislocation, or con-
mus, microphthalmia, hypoplastic face or facial tractures. The neonate is capable of reacting to
droop, micrognathia, abnormal shape/size of the moving persons or objects within sight or grasp,
nose, asymmetry of smile, high-arched palate, both for large and small objects. Neonates can
congenital cataracts, small or simple ears, and visually fixate on a face or light in their line of
preauricular skin tag/dimple and cleft lip/palate. vision (American Academy of Pediatrics 1996).
The quality of the cry can suggest neurological
1.2.2.3 Functional Capabilities involvement. A term newborn’s cry is usually
Neonatal function is primarily reflex activity and loud and vigorous. A weak or sedated neonate
necessitates the assessment of infantile automa- will cry only briefly and softly or may just whim-
tisms, i.e., those specific reflex movements per. A high-pitched cry is often associated with a
which appear in normal newborns and disappear neurological abnormality or increased intracra-
at specific periods of time in infancy. Table 1.3 nial pressure (Freedman et al. 2009). Functional
outlines the primitive reflexes in more detail capabilities of the preterm infant will vary by
(Slota 1983a). Functional examination may gestational age. Premature infants demonstrate
begin by observation of the neonate in supine less strength and decreased muscle tone com-
and prone positions, noting spontaneous activity pared to a term infant. Table 1.3 provides some of
in each position and the presence of primitive the key changes and the approximate time when
reflexes. The posture of the neonate is one of selected milestones appear in most premature
partial flexion with diminishing flexion of the infants (McGee and Burkett 2000).
legs as the neonate ages. Observe for hypotonia,
which could indicate neurologic deficit or a 1.2.2.4 Vulnerabilities
genetic/metabolic disorder. Look for random The most critical need of both the term and prema-
movements of the extremities and attempt to dis- ture neonate is for the establishment of adequate
tinguish single myoclonic twitches, which are respiratory activity with appropriate oxygenation.
normal, from repetitive movement seen with sei- Respiratory immaturity added to the neurological
zures. Observe for symmetry of movements. insults from seizures, congenital conditions such as
Care should be taken to observe for infantile spina bifida and genetically linked syndromes, as
spasms characterized by atonic head drops well as intraventricular hemorrhage and hydroceph-
accompanied by the arms rising upward. Some alus all have the capability to severely limit the neo-
neonates have an excessive response to arousal nates’ ability to buffer these conditions. Infections,
with “jitteriness” or tremulousness. This is a an immature immune system, and gastrointestinal
low-amplitude, rapid shaking of the limbs and deficiencies also can severely compromise the neo-
jaw. It may appear spontaneously and look like a nate’s ability to dampen the physiological effects of
seizure. However, unlike seizures, jitteriness neurological conditions. For the preterm neonate
usually follows some stimulus, can be stopped with a neurological disorder, dampening the effects
by holding the limb or jaw, and does not have becomes even more crucial and makes the preterm
associated eye movements or respiratory change. infant vulnerable to multisystem failures.
When prominent, slow, and coarse, it may be Developmental care teams can be mobilized to aug-
related to central nervous system stress or meta- ment the neonate’s capacity for optimal growth and
bolic abnormalities, but otherwise it is often a interaction with his or her environment.
Table 1.3 Interpreting the neurological examination in the neonate/infant

Reflexes Methods of testing Responses/comments
Palmar grasp Press index finger against palmar Infant will grasp the finger firmly. Sucking
P – birth surface; compare grasp of both facilitates grasp. Meaningful grasp occurs
D – 3–4 months hands after 3 months
Plantar grasp Press index finger to sole of the Toes will flex in an attempt to grasp the
P – birth foot finger
D – 8–10 months
Acoustic – cochleopalpebral Create loud noise Both eyes blink. This reflex may be
difficult to elicit in first few days of life
Rooting Stroke perioral skin or cheek Mouth will open and infant will turn to
P – birth stimulated side
D – 3–4 months when awake
D – 3–8 months when asleep
Sucking Touch lips of infant Infant will suck with the lips and the
P – birth tongue
D – 10–12 months
Trunk incurvation (Galants) Hold infant prone in one hand Trunk will curve to stimulated side
P – birth and stimulate one side of the
D – 2 months back about 3 cm from midline
Vertical suspension positioning Support baby upright with hands Legs flex at hips and knees. Legs extend
P – birth under axillae after 4 months. Scissoring of legs indicates
D – 4 months spastic paraplegia
Placing response Hold baby upright with hands Infant will flex hip and knee and place the
P – few days after birth under axillae and allow dorsal foot on table with stepping movement
D – 10–12 months surface of foot to touch
undersurface of table without
plantar-flexing foot
Stepping response Hold infant upright with hands Infant will pace forward alternating feet
P – birth under axillae and feet flat on
D – 3 months table
Tonic neck reflex Turn the head to one side Arm and leg on same side extend and
P – birth to 6 weeks others flex
D – 4–6 months
Traction response Pull infant from supine position Shoulder muscle movement will be noted
to sitting with his hands
Perez reflex Hold in prone position with one Infant will extend the head and spine, flex
P – birth hand and move the thumb from knees on the chest, cry, and urinate
D – 3 months sacrum to the head
Moro reflex Create loud noise or sudden Infant stiffens, extremities extend, index
P – birth movement such as extension of finger and thumb form C shape, and
D – 4–6 months the infant’s neck fingers and toes fan
Obtained from McGee and Burkett (2000)
P present, D disappears
In the United States, all 50 states have laws et al. 2013; Knoeker et al. 2015). Despite this,
that require car seats for infants and toddlers. motor vehicle accidents continue to be one of the
Since the implementation of such passenger leading causes of death for children and youth.
safety laws, hospitals and health-care providers These statistics emphasize the need to provide
have played an important role in providing aware- appropriate car safety education to caregivers
ness, education, and access to equipment (Elliott during the assessment.
1.2.2.5 T ips in Approach to Child/ closure of the sutures may indicate increased
Family intracranial pressure or hydrocephalus, warrant-
Observation of the neonate at rest is the first step ing further evaluation. Inspection of the scalp
in a comprehensive approach to neurological should include observation of the venous pattern,
assessment of the neonate. Usually, the head can because increased ICP and thrombosis of the
be inspected and palpated before awakening the superior sagittal sinus can produce marked
neonate and measuring the head circumference. venous distention (Dlamini et al. 2010).
Most neonates arouse as they are unwrapped, and Observation of the spine should include an
responses to stimuli are best assessed when the examination for lumps, bumps, dimples, midline
neonate is quietly awake. As the neonate arouses hemangiomas, and tufts of the hair. Examination
further, the strength of his spontaneous and active of rectal tone for an anal wink should be per-
movement can be observed and cranial nerves formed, especially when suspicion is present for
assessed. Stimulation of selected reflexes, like an occult spinal dysraphism. The absence of an
the Moro reflex, and eye exam are reserved for anal wink is noted when the anal sphincter does
last, since they usually elicit vigorous crying. The not contract when stimulated or there is a lack of
typical cry of an infant is usually loud and angry. contraction of the anal sphincter during the rectal
Abnormal cries can be weak, shrill, high pitched, examination. Identification of a sensory level of
or catlike. Crying usually peaks at 6 weeks of function in an infant with a spinal abnormality
age, when healthy infants cry up to 3 h/day, and can be very difficult. If decreased movement of
then decreases to 1 h or less by 3 months extremities is noted, observe the lower extremities
(Freedman et al. 2009). The ability to console, for differences in color, temperature, or perspira-
including the sucking response, can be evaluated tion, with the area below the level of spinal abnor-
whenever the neonate is agitated. The sequence mality usually noted to be cooler to touch and
of the examination can always be altered in without perspiration (McGee and Burkett 2000).
accordance with the newborn’s state or situation.
Excessive stimulation or cooling may cause 1.2.3.2 Functional Capabilities
apnea or bradycardia in the preterm neonate, and Assessment of the infant’s function requires
components of the exam may need to be post- knowledge of normal developmental landmarks.
poned until the neonate is stabilized. Refer to Table 1.4.
1.2.3.3 Vulnerabilities
1.2.3 Infant When typical ages for maturation of selected mile-
stones are not reached and/or primitive reflexes per-
1.2.3.1 Physical Development sist beyond their expected disappearance,
Infancy is defined as 30 days to 12 months of age. neurological problems may be implicated. Most
An infant’s head grows at an average rate of 1 cm primitive reflexes such as the Moro reflex have dis-
per month over the first year. Palpation of the appeared by the age of 4–6 months, with reflexes of
head should reveal soft and sunken fontanels sucking, rooting during sleep, and placing responses
when quiet and in the upright position. A bulging lingering until later in infancy. Specifically if there
fontanel in a quiet infant can be a reliable indica- are persistent rigid extension or flexion of the
tor of increased intracranial pressure. However, extremities, opisthotonos positioning (hyperexten-
vigorous crying of an infant can cause transient sion of the neck with stiffness and extended arms
bulging of the fontanel. The posterior fontanels and legs), scissoring of the legs, persistent low tone
will close by 1–2 months of age with wider vari- of all or selected extremities, asymmetry of move-
ability in the anterior fontanel, often closing ment or reflexes, and asymmetrical head rotation to
between 6 and 18 months of age. If the sutures one side, these behaviors alone can suggest central
close prematurely and skull shape becomes nervous system disease or insult during this rapid
abnormal, evaluate for craniosynostosis. Delayed period of growth and development (Hobdell 2001).
1
Table 1.4 Age-appropriate neuro assessment table (Wallace and Disabato)
Echoes two or
Age Gross motor Fine motor Personal/social more words
Newborn Head down with ventral suspension Hands closed With sounds, quiets if crying; cries if Crying only monotone
Flexion posture Cortical thumbing (CT) quiet; startles; blinks
Knees under abdomen – pelvis high
Head lag complete
Head to one side prone
4 weeks Lifts chin briefly (prone) Hands closed (CT) Indefinite stare at surroundings Small, throaty noises
Rounded back sitting head up momentarily Briefly regards toy only if brought in
front of the eyes and follows only to
midline
Almost complete head lag Bell sound decreases activity
6 weeks In ventral suspension head up momentarily in Hands open 25% of time Smiles Social smile (first cortical
same plane as body input)
Prone: pelvis high but knees no longer under the
abdomen
2 months Ventral suspension; head in same plane as body Hands open most of the time Alert expression Cooing
(75%) Smiles back
Lifts head 45° (prone) on flexed forearms Active grasp of toy Vocalizes when talked to Single vowel sounds (ah, eh,
Sitting, back less rounded, head bobs forward Follows dangled toy beyond midline uh)
Energetic arm movements Follows moving person
3 months Ventral suspension; head in same plane as body Hands open most of the time Smiles spontaneously Chuckles
Neurological Assessment of the Neonate, Infant, Child, and Adolescent
(75%)
Lifts head 45° (prone) on flexed forearms Active grasp of toy Hand regard “Talks back” if examiner nods
head and talks
Sitting, back less rounded, head bobs forward Follows dangled toy 180° Vocalizes with two different
Energetic arm movements Promptly looks at object in midline syllables (a-a, oo-oo)
Glances at toy put in hand
4 months Head to 90° on extended forearms Active play with rattles Body activity increased at sight of toy Laughs out loud increasing
inflection
Only slightly head lag at beginning of movement Crude extended reach and grasp Recognizes bottle and opens mouth No tongue thrust
Bears weight some of time on extended legs if Hands together for nipple (anticipates feeding with
held standing excitement)
Rolls prone to supine Plays with fingers
11
Downward parachute Toys to the mouth when supine

(continued)
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12
Echoes two or
6 months Bears full weight on legs if held standing Reaches for toy Displeasure at removal of toy Shy with strangers
Sits alone with minimal support Palmar grasp of cube Puts toy in the mouth if sitting Imitates cough and protrusion
of the tongue
Pivots in prone Lifts cup by handle Smiles at mirror image
Rolls easily both ways Plays with toes
Anterior propping
7 months Bears weight on one hand prone Stretches arms to be taken Murmurs “mom” especially if
crying
Held standing, bounces Keeps the mouth closed if offered Babbles easily (Ms, Ds, Bs,
more food than wants Ls)
Sit on hard surface leaning on hands Smiles and pats at mirror Lateralizes sound
9 months Sits steadily for 15 min on hard surface Picks up small objects with Feeds cracker neatly Listens to conversation
Reciprocally crawls index finger and thumb (pincer Drinks from cup with help Shouts for attention
Forward parachute grasp) Reacts to “strangers”
10 months Pulls to stand Pokes with index finger, prefers Nursery games (i.e., pat-a-cake), Will play peekaboo and
small to large objects picks up dropped bottle, waves pat-a-cake to verbal command
Sits erect and steadily (indefinitely) bye-bye Says Mama, Dada
Sitting to prone appropriately, finds the hidden
Standing: collapses and creeps on hands and toy (onset of visual memory)
knees easily
Prone to sitting easily
Cruises – laterally
Squats and stoops – does not recover to standing
position
12 months Sitting; pivots to pick up object Easy pinch grasp with the arm Finds hidden toy under cup One other word (noun)
off the table besides Mama, Dada (e.g., hi,
Walks, hands at shoulder height Independent release (e.g., cube Cooperates with dressing bye, cookie)
into cup)
Bears weight alone easily momentarily Shows preference for one hand Drinks from cup with two hands
Marks with crayon on paper
Insists on feeding self
J.A. Disabato and D.A. Daniels
Echoes two or
1
13 months Walks with one hand Mouthing very little Helps with dressing Three words besides Mama,
Dada
Explores objects with fingers Offers toy to mirror image Larger receptive language
Unwraps small cube Gives toy to examiner than expressive
Imitates pellet bottle Holds cup to drink, tilting the head
Affectionate
Points with index finger
Plays with washcloth, bathing
Finger feeds well but throws dishes on
the floor
Appetite decreases
14 months Few steps without support Deliberately picks up two small Should be off bottle Three to four words
blocks in one hand expressively minimum
Peg out and in Puts toy in container if asked
Opens small square box Throws and plays ball
15 months Creeps up stairs Tower of two cubes Feeds self fully leaving dishes on tray Four to six words
“Helps” turn pages of book
Kneels without support Scribbles in imitation Uses spoon turning upside down, Jargoning
spills much
Gets to standing without support Completes round peg board Tilts cup to drink, spilling some Points consistently to indicate
Stoop and recover with urging Helps pull clothes off wants
Cannot stop on round corners suddenly Pats at picture in book
Collapses and catches self
Neurological Assessment of the Neonate, Infant, Child, and Adolescent
18 months Runs stiffly Tower of three to four cubes Uses spoon without rotation but still One-step commands, 10–15
spills words
Rarely falls when walking Turns pages two to three at a May indicate wet pants Knows “hello” and “thank
time you”
Walks upstairs (one hand held one step at a time) Scribbles spontaneously Mugs doll More complex “jargon” rag
Climbs easily Completes round peg board Likes to take off shoes and socks Attention span 1 min
Walks, pulling toy or carrying doll easily Knows one body part Points to one picture
Throws ball without falling Very negative oppositions
Knee flexion seen in gait
(continued)
13
14
Echoes two or
21 months Runs well, falling some times Tower of five to six cubes May briefly resist bathing Knows 15–20 words and
combines 2–3 words
Walks downstairs with one hand held, one step at Opens and closes small square Pulls person to show something Echoes two or more
a time box
Kicks large ball with demonstration Completes square peg board Handles cup well Knows own name
Squats in play Removes some clothing purposefully Follows associate commands
Walks upstairs alternating feet with rail held Asks for food and drink
Communicates toilet needs
Helps with simple household tasks
Knows three body parts
24 months Rarely falls when running Tower of six to seven cubes Uses spoon, spilling little Attention span 2 min
Walks up and down stairs alone one step at a time Turns book pages singly Dry at night Jargon discarded
Kicks large ball without demonstration Turns door knob Puts on simple garment Sentences of two to three
words
Claps hands Unscrews lid Parallel play Knows 50 words
Overthrow hand Replaces all cubes in small box Assists bathing Can follow two-step
commands
Holds glass securely with one Likes to wash and dry hands Refers to self by name
hand Plays with food + body parts Understands and asks for
“more”
Tower of 8 Asks for food by name
Helps put things away Inappropriately uses personal
pronouns (e.g., me want)
Identifies three pictures
3–5 years Pedals tricycle Copies circles Group play Uses three-word sentences
Walks upstairs alternating feet Uses overhand throw Can take turns
Tiptoe jump with both feet
5–12 years Activities of daily living Printing and cursive writing Group sports Reads and understands
content
Spells words
Wallace and Disabato (2014)
J.A. Disabato and D.A. Daniels
1.2.3.4 T ips in Approach to Child/ and the arms swing at the sides for balance.
Family Improvements in balance and agility emerge with
A comprehensive review of the infant’s develop- mastery of skills such as running and stair climb-
mental milestones, activity level, and personality ing. Inspection of the toddler head and spine is
is critical when obtaining a history from the par- aimed at recognition of subtle neurological
ent. Pictures of the infant at birth, home videos, abnormalities like new-onset torticollis, abnor-
and baby book recordings may trigger additional mal gait patterns, and loss of previously achieved
input to supplement the history. Approach to the milestones. Cortical development is 75% com-
physical exam in early infancy (before infant sits plete by the age of 2 years; therefore, the neuro-
alone at 4–6 months) differs from the older infant. logical response of the child over 2 years old is
During early infancy, they can be placed on the similar to that of the adult. Most toddlers are
examining table assessing for positioning abili- walking by the first year, though some do not
ties in prone and supine. Reflexes can be elicited walk until 15 months. Assessment of language
as extremities are examined. The onset of stranger close to the age of 3 is the first true opportunity
anxiety at 6–8 months of age presents new chal- for a cognitive assessment.
lenges and can result in clinging and crying
behaviors for the infant. Reducing separations 1.2.4.2 Vulnerabilities
from the parent by completing most of the exam Greater mobility of the toddler gives them access
on the parent’s lap can diminish these responses. to more and more objects, and, as exploration
This is a time to gain cooperation with distrac- increases, this makes them more at risk for injury.
tion, bright objects, smiling faces, and soft voices Physical limits on their explorations become less
(Schultz and Hockenberry 2011). The use of pic- effective; words become increasingly important
ture books between infant and parent can provide for behavior control as well as cognition. Delayed
an environment to demonstrate language abili- language acquisition can be identified at this age
ties. The assessment should proceed from the and may represent developmental issues previ-
least to the most painful or intrusive to maximize ously unrecognized. If language delay is sus-
the infant’s cooperation and is often performed in pected, then a referral to speech therapy for a
a toe-to-head fashion. Evaluation of muscle formal evaluation should be initiated by
strength, tone, and cerebellar function should 9–15 months of age.
precede the cranial nerve examination with pal-
pation, auscultation, and measurement of the 1.2.4.3 T ips in Approach to Child/
head reserved for last. Family
The neurological exam is approached systemati-
cally beginning with an assessment of mental/
1.2.4 Toddler emotional status and following with evaluation of
cranial nerves and motor and sensory responses
1.2.4.1 Physical Development and reflexes. Much of the neurologic examina-
During the toddler years of ages 1–3, brain tion can be completed by careful observation
growth continues at a more gradual rate. Head before ever laying hands on the child. Watch as
growth measurements for boys average 2.5 cm the child plays and interacts with his environ-
and girls slightly less with a 2-cm increase. From ment. Interactive games such as peekaboo, reach-
ages 24 to 36 months, boys and girls both slow to ing for toys, and turning to the sound of the bell
only l cm per year. The toddler’s head size is only can make the examination fun and less traumatic.
one-quarter the total body length. The toddler The toddler may interact better on the parent’s
walks with a wide-based gait at first, knees bent lap or floor of the exam room. Initially, minimal
as feet strike the floor flat. After several months physical contact is urged. Later inspection of the
of practice, the center of gravity shifts back and body areas through play with “counting toes” and
trunk stability increases, while the knees extend “tickling fingers” can enhance the outcomes of
the exam. Exam equipment should be introduced 1.2.5.3 T ips in Approach to Child/
slowly and inspection of equipment permitted. Family
Auscultate and palpate the head when quiet. To maximize the preschooler’s cooperation dur-
Traumatic procedures such as head measure- ing the neurological assessment, many
ments should be performed last. Critical portions approaches can be offered. The presence of a
of the exam may require patient cooperation, and reassuring parent can be more comforting to a
consideration should be given to completing preschooler than words. The older preschooler
those components first (e.g., walking and stoop- may be willing to stand or sit on the exam table,
ing abilities). while the younger preschooler may be content to
remain in the parent’s lap. If the preschooler is
cooperative, the exam can proceed from the head
1.2.5 Preschooler to toe; if uncooperative, the approach should be
as for the toddler exam. Equipment can be
1.2.5.1 Physical Development offered for inspection and a brief demonstration
This period is defined as ages 3–5 years. Visual of its use. Fabricating a story about components
acuity reaches 20/30 by age 3 and 20/20 by age 4. of the assessment, such as “I’m checking the
Handedness is usually established after age 3. If color of your eyes,” or making games out of
handedness is noted much earlier, spasticity or selected portions, can maximize the child’s
hemiparesis should be suspected. Note if the cooperation. Using positive statements that
child is left-handed and if there is familial history expect cooperation can also be helpful (e.g., “I
of left-handedness. Bowel and bladder control know you can open your mouth” or “Show me
emerge during this period. Daytime bladder con- your pretty teeth”).
trol typically precedes bowel control, and girls
precede boys. Bed-wetting is normal up to age
4 years in girls and 5 years in boys (American 1.2.6 School-Age Child
Academy of Pediatrics 2011). Although the brain
reaches 75% of its adult size by the age of 2 years, 1.2.6.1 Physical Appearance
cortical development is not complete until the This is the phase of the middle childhood years
age of 4 years. aged 5–12. The head grows only 2–3 cm through-
out the entire phase. This is a reflection of slower
1.2.5.2 Vulnerabilities brain growth with myelination complete by
Highly active children face increased risks of 7 years of age (Amidei et al. 2010). Muscular
injury. Helmet and bike safety programs are essen- strength, coordination, and endurance progres-
tial ingredients to reducing such risks. Given the sively increase throughout this growth period.
escalating language abilities of the preschooler, School children’s skills at performing physical
speech and language delays can be detected with a challenges like dribbling soccer balls and play-
greater assurance than in the toddler period. ing a musical instrument become more refined
Persistent bowel or bladder incontinence may with age and practice. School-aged children are
indicate a neurogenic bladder that can be a sign of able to take care of their own immediate needs
spine anomalies such as a tethered cord. and are generally proficient in the activities of
Preschoolers can control very little of their daily living. Motor skills are continuing to being
environment. When they lose their internal con- refined. Children at this age participate in extra-
trols, tantrums result. Tantrums normally peak in curricular and competitive activities outside of
prevalence between 2 and 4 years of age. Tantrums school in arenas such as academic clubs, sports,
that last more than 15 min, or if they are regularly art, and music, and a history of socialization
occurring more than three times a day, may reflect should be obtained. Their world is expanding,
underlying medical, emotional, or social prob- and accomplishments progress at an individual
lems as well as expressive language delay. pace.
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CHAPTER VI.
A Ball.
By the time the summer was over, many of Lettice’s friends had left
the neighborhood. Rhoda had gone to Washington to join her father,
who was still detained in the capital city. Mr. Clinton, too, was there.
In October both Mr. Tom Hopkins and Lettice’s father marched away
to the Canada border, and among the armed vessels which
Baltimore sent out to annoy the enemy was one commanded by Joe
Hopkins; this had started down the Chesapeake in August, and
Patsey was wistfully looking for news from her absent lover. Betty’s
pleadings had kept her husband at home, so far; and Jamie,
although he threatened each day to follow his father, still lingered.
“You’d better stay at home and protect us,” Betty and Lettice would
say. “Suppose the enemy should come up the Chesapeake, where
would we be? And if I were left a young widow, William, think how
sad,” Betty would say as a final argument.
“I think I will go to sea with Cousin Joe when he comes back,” James
at last concluded. “I tell you we’re licking the British on the water,
whatever we may be doing on land. Commodore Barney captured
fifteen vessels in the forty-five days he was running along the coast,
and news has come that the Wasp has captured the Frolic, and the
United States has the Macedonian, if last reports are correct.”
“Good!” cried Lettice. “I wonder how Rhoda likes that.”
James looked down, and with the toe of his boot rolled over one of
the hounds at his feet; then he looked up, saying, “And Robert
Clinton, how do you suppose he takes it?”
Lettice gave her head a little toss. “What do I care how he takes it! Is
there news from Canada, Brother William?”
“No good news. We must be content with our victories at sea, for the
present. Our little state has nothing to be ashamed of in her naval
exploits.”
Just then the smart rap of a whip-handle on the door announced a
visitor, and Birket Dean walked in. “I was coming this way, Miss
Lettice,” he said, after greeting them all, “and I brought along this
letter that came for you on one of the boats.”
“A letter?” Lettice eagerly held out her hand, and tore open the letter
fastened with seals, for as yet envelopes were unknown. She gave
her attention to the closely written pages, then looked up, and said
animatedly: “Oh, brother! oh, Sister Betty, Rhoda wants me to come
to Washington for a visit! I should so love to go to see the President
and Mrs. Madison, and oh, do say I may go!”
“Alone?” returned her brother William, smiling. “You wouldn’t expect
me to leave Betty and the baby to take you, would you?”
“Jamie could take me. You would like nothing better, would you,
Jamie?”
“I’d like to, yes; but—”
“Oh, well, never mind; I can go as far as Baltimore with Aunt Martha,
and she can find some one in whose charge to place me. I will see
Aunt Martha this very evening.”
“Will you ride over with me?” Birket asked eagerly.
“Yes, if you will stay to supper. Here, Jamie, I know you are dying to
see this, and as there are no secrets in it, you may as well have the
pleasure of perusing it.” And Lettice tossed her letter to her brother
James.
It was a lovely ride down the road in the hush of an October evening;
the landscape, taking on an autumnal hue, showed a soft
envelopment of purple mist. To the right lay the blue bay, across
which dimly appeared the spires of the little town of Annapolis.
“It is truly a beautiful scene,” said Lettice, gazing around her. She
looked like a bit of autumn herself in her scarlet jacket, and with the
shining wing of a swamp blackbird in her hat. She had, it is true,
some compunctions in accepting the wing, being of a most tender
heart. Birket had given it to her, and quieted her protests by telling
her how the thieving birds had stolen the corn and must be shot, if
the crops must be protected. “Better that than to have them caught
by a prowling beast, for we shoot them and they die instantly,
otherwise who knows but that they may suffer tortures.”
Lettice had stroked the bright feathers thoughtfully, saying, “Since he
is dead, I may as well wear his feathers, but bring me no more, Birk;
it makes me sad to see them.”
“And how about the foxes?” Birket had said.
“Ah, the foxes, they are thieves, too; but I always shut my eyes when
the hounds pounce on them. ’Tis a pity the world is not big enough
for us and them, too.”
The conversation had taken place a day or two before, for Birket was
a frequent visitor. His father’s plantation lay on the other side of Mr.
William Hopkins’s, but on account of the wrigglings in and out of a
little creek, it was easier reached by water than by land.
“It is a truly lovely scene,” Lettice repeated.
“And yet you want to leave it,” Birket returned reproachfully.
“So I do, for I love new scenes, and Rhoda says there are many gay
doings at the capital.”
“It is not much of a place,” Birket remarked; “not near so fine as
Baltimore.”
“No, of course not. Baltimore is the third city in the Union.
Nevertheless, seeing that I have been to Baltimore and have never
been to Washington, I shall like to go to the least familiar place.”
“Mr. Clinton is there?” Birket asked hesitatingly.
Lettice gave her horse a gentle flick with her whip. “I don’t know,” she
said shortly, as the horse changed his walk to a canter.
A few weeks later saw the two girls, Lettice and Rhoda, together in
Washington, Aunt Martha having readily found an escort for Lettice
in the person of one Mr. Francis Key, whose affability and courtesy
lessened the tedium of the long trip, for it was a day’s journey by
coach from Baltimore to Washington.
Dark though it was when Lettice arrived, she could perceive that
Washington had little pretensions to being a fine place. After leaving
the busy city of Baltimore, with its forty thousand inhabitants, its
streets bright with lamps and full of the noise of rushing feet, of
singing sailors, and rumbling carts, Washington, where scarce more
than five thousand persons dwelt, seemed little more than a village,
full of mud-holes, and showing a small number of houses at
scattered distances. Lettice, however, was not to stay in Washington,
for after the coach had rattled over the newly laid pike, and she had
dimly discerned the white walls of the unfinished Capitol, she was
helped down from her seat and entered a hackney coach, which was
driven up and down hill, over Rock Creek, through mud and mire,
until it arrived in Georgetown, a more habitable place than that which
they had just left. Comfortable, spacious houses stood to the right
and left of them—houses which to-day, dingy and dilapidated, give
small evidence of having witnessed the brilliant scenes once of
frequent occurrence within their walls.
Lettice was welcomed with more heartiness than she had expected
from the reserved Rhoda, and she parted with her kind escort, after
many thanks for his thoughtful attentions.
“You must be sadly weary, Lettice,” said Rhoda, as she led her friend
upstairs to a room overlooking the blue Potomac. “I well remember
how fatigued I was when I arrived; but I hope you will soon get over
your journey’s effects, for there are to be fine doings here next week,
and you must be in your best trim. Did you bring your prettiest
gowns?”
“I did, indeed, and a new one is to be sent as soon as the mantua-
maker has it finished. Are you having a good time here, Rhoda?”
“Fairly pleasant, though the wretched war stirs up all sorts of ill
feeling, and one never knows what will happen, or what unpleasant
things one may hear; yet I have much less to stand than the
President’s wife, and should not complain.”
“The President’s wife, Mrs. Dolly Madison? Is any one so churlish as
to show ill-will toward her?”
“Indeed, yes. She is sometimes treated with much discourtesy,
because they impute all the woes of the country to her husband.”
“As if she could help that! What gumps some people be! And have
you seen Mrs. Madison, Rhoda? Do you know her?”
“I have met her several times, and she is a charming lady.”
“And your beaux, Rhoda? What of them?” The two girls looked at
each other, and both blushed faintly; then Lettice, summoning up
courage, asked, “Are you promised to Mr. Clinton, Rhoda?”
Rhoda looked down and answered faintly, “Not yet.”
Lettice gave her head a little toss, and a haughty look came into her
dark blue eyes. “You mean that you could be if you wanted?”
“My father wishes it very much.” Rhoda’s eyes were still downcast.
“Your father? And how about you and the gentleman himself?”
“I don’t know.”
“Oh, you don’t?” There was some consolation in this, Lettice thought,
and she determined to watch for herself.
The capital, raw and incomplete as it looked, still furnished more
gayeties than Lettice found at home. Here were gathered the
statesmen of the day, and the girl was all eagerness to have this or
that important personage pointed out to her. Henry Clay and John C.
Calhoun, John Randolph of Roanoke, a great friend of Lettice’s late
travelling companion, Mr. Frank Key, and many other distinguished
men were to be seen in the city during the session of Congress. The
appearance of some of these rather disappointed Lettice. She
thought the President a very insignificant person for so great an
office, she wrote home to James, and Mr. Randolph was the oddest
looking man she had ever seen.
“There is to be a great ball at Tomlinson’s hotel,” was one of the first
pieces of news that Rhoda gave her friend.
“And shall we go?” Lettice asked.
“I am not sure. My father, you know, disapproves of the war, but—”
“Mine doesn’t,” Lettice interrupted triumphantly, “and perhaps I can
get some one to take me. Should you mind if I did, Rhoda?”
“I should like to go, too,” Rhoda returned, “for there will be a most
distinguished company present: the President and Mrs. Madison, the
Secretaries, and—oh, everybody. It is to be in honor of the capture of
the Guerrière and the Alert.”
“We must go, if there is any way,” Lettice cried. “Rhoda, tell me, do
you really feel so incensed at the idea of a war as you pretend?”
Rhoda did not answer at once, and then she said slowly, “I think with
my father that it is unwise; but once in it, I think we should do our
best to win.”
“Good!” cried Lettice. “I’d like to tell Brother James that.”
“Your brother James?” Rhoda repeated a little unsteadily. “Has he
gone to the war?” She had not made any inquiry about him, and
Lettice had wickedly refrained from mentioning him.
“He hasn’t gone, exactly. He belongs to the militia, and so does
Brother William, but James says when Cousin Joe comes back he
intends to join him, for he prefers service at sea.”
“Your cousin Joe, then, has not come back yet? And his marriage, is
it postponed?”
“He has not returned, and the marriage has to be put off indefinitely.
Poor dear Patsey! All those pretty gowns waiting for her wedding
day, and she does not know when she can wear them! Cousin Joe
made one short trip, and then came back to Baltimore. He started
out again, but not a word has been heard from him.”
“Poor Patsey!” Rhoda looked very thoughtful for a moment; then she
jumped up from the stiff chair in which she was sitting. “I’ll write a
note, Lettice,” she said. “I don’t doubt we can go to the ball if you so
desire it. I have friends at court, even if my father does not uphold
the administration. I can write to Mrs. Paul Hamilton, who knew my
mother well, and has been most kind to me.”
“The wife of the Secretary of the Navy?”
“Yes, she has a son in the navy and a daughter here. No fear,
Lettice, but that we can go with them, and take Mr. Clinton as our
escort.”
Lettice shrugged her shoulders, but made no comment, though when
it was known that they were to go to the ball, she was in a twitter of
excitement, and declared she meant to captivate the highest
dignitary there, if she could.
“That will not be difficult,” Mr. Clinton murmured, for her ear alone.
The girl turned, and gave him a little scornful look. Despite the young
man’s efforts at being polite and attentive, he had not met with much
encouragement, and never was allowed an opportunity for one of
those confidential talks he had found so pleasant during the summer.
Into a gay and brilliantly lighted room in Tomlinson’s hotel, on the
night of December 8, 1812, Rhoda and Lettice entered. The former
looked very fair and elegant in her India muslin, her delicate features
and fair skin set off by a scarf of pale blue. Lettice, with her brilliant
color, her dancing curls, and pretty figure, looked not less fair in her
gown of pink, with her floating scarf of white, skilfully embroidered.
They had scarcely come into the ball-room, the walls of which were
decorated with the captured flags of the Alert and the Guerrière,
when there was heard a great cheering and noise of excitement.
“What is it?” whispered Lettice, half in alarm.
“Nothing to be terrified at, you may be sure,” returned Mr. Clinton,
“for every one is smiling and eager. See, Mrs. Madison is talking
quite gayly.”
Lettice stood on tiptoe the better to see, as into the room trooped a
crowd of young gentlemen all escorting a young man who bore aloft
a flag.
“’Tis young Mr. Hamilton,” cried Rhoda. “See, Captain Hull and
Captain Stewart receive the flag. They are taking it to Mrs. Madison.
It must be a captured flag.”
Lettice watched while, amid resounding cheers, the flag was placed
by the side of those taken from the Alert and the Guerrière. “It is a
fine sight,” she exclaimed. “I am so glad I came!”
She was so full of enthusiasm that she did not notice that she spoke
to a stranger, but the young man addressed smiled down at her and
replied: “So am I. Have you heard what it is all about?”
“No, please tell me.”
“It is the flag of the Macedonian. She was captured on October 25,
by Captain Decatur of the frigate United States, and Mr. Hamilton
has just brought official notice of it to his father.”
“Oh, thank you.” Lettice’s lovely eyes were shining with delight. “I am
so glad.”
“Lettice,” came Rhoda’s voice severely. Then Lettice realized that
she did not know this young man, and blushing, she followed
Rhoda’s lead. The young man stood looking after them. “I wonder
who the dear little girl is,” he said to himself. “I must find out.”
“Who was that, Lettice?” Rhoda asked.
“I don’t know. Oh, Rhoda, I was so excited that I spoke to him
without realizing that he was a stranger. I am afraid it was a dreadful
thing to do. Don’t tell Aunt Martha nor Mrs. Hamilton.”
“No, I will not; but you must not do such things. I shall have to keep a
strict eye upon you.”
“I am afraid you will,” replied Lettice, meekly. However, after the
supper, when the manager of the ball proposed as a toast, “Decatur
and the officers and the crew of the frigate United States,” and after
the most exciting evening she had ever known, as Lettice was about
to leave the ball-room, she turned for one last, parting look, and from
across the room came a smile of recognition from the strange young
gentleman, and though Lettice was following Rhoda most
decorously, she could not resist an answering smile as she turned
away.
CHAPTER VII.
Captured.
By this time the ports and harbors of the Chesapeake were declared
in a state of blockade, and after her visit in Washington was over,
Lettice returned to Baltimore to hear that little fleets of British ships
were appearing off the coast.
“You are much safer here than at home,” Mrs. Tom Hopkins said; “for
if the British should come up the bay, there is no knowing what will
happen. Think how they have burned and plundered lower Virginia.
We may yet see our homes in the country burned over our heads.”
“Do you really think so, Aunt Martha?” Lettice asked apprehensively.
“One cannot tell,” Mrs. Hopkins returned, shaking her head. “Alas,
this foolish war! It has taken my husband from me and may rob me
of my home.”
“Why don’t you go to Boston when Mr. Kendall and Rhoda go?”
Lettice asked demurely.
“Because my duty is here,” her aunt replied, a little sharply. “I shall
not neglect that for the sake of my own comfort and convenience. I
was not brought up that way.”
“Isn’t it a pity that all the Massachusetts people don’t feel so?” Lettice
said slyly.
“Why, child, what do you mean?”
“I mean that they don’t want the war to go on because it interferes
with their comfort and convenience, and yet it is their duty to stand
by their country’s rights.”
“You don’t know what you are talking about,” replied her aunt. “A chit
of a girl like you doesn’t know anything about politics.”
“I’ve been to Washington, and I heard, oh, so much talk about it
there! I know all about war matters,” Lettice returned triumphantly.
“You ought to have heard Mr. Clay and Mr. Calhoun! And even Mr.
Randolph, I believe, would think we ought to defend ourselves if the
enemy invades the country.”
Mrs. Hopkins went back to her first grievance. “And they will invade
it. Nothing but discouraging news from your uncle, and no news at all
from Joseph. We are not strong enough to resist this invading foe.”
“But just look at the victories at sea!”
“A few, to be sure; but as soon as the British are roused to a sense
of the real situation, our little navy will be wiped out. I am told that
they have said they will chastise us into submission.”
“They will, will they? I’d just like to see them!” Lettice’s eyes flamed,
and she stamped her foot in rage.
“Why, Lettice, what a temper you display!” said Mrs. Hopkins,
viewing Lettice’s angry tears with disapproval. “You never see Rhoda
fairly cry with temper.”
Lettice’s remembrance of Rhoda’s reserved manner and her quiet
self-control served to calm her. “I don’t care,” she said. “I know she
boils inside, whether she shows it or not.” Then she sat very still for a
time. A picture of Rhoda’s tranquil face with its small features, her
smooth light hair, her neat slim figure, rose before her. She
wondered if at that moment she and Robert Clinton were walking the
streets of old Georgetown. From this her thoughts wandered to the
old graveyard, and she jumped up with a suddenness that startled
her aunt. “Do you suppose, Aunt Martha,” she said, “that Brother
Tom wasn’t drowned after all?”
Mrs. Hopkins put down her work and looked at her niece in surprise.
“What in the world gave you that notion, Lettice?”
“I don’t know. Often when I’ve been down in the graveyard at home
I’ve thought of it.”
“His body was never recovered, it is true,” Mrs. Hopkins returned
thoughtfully. “It is possible, but not probable, and I’d put any such
notion out of my head, if I were you. He was not only a trial to your
parents, but he was not a benefit to society.”
“No, he wasn’t, and yet, at his best, he was a dear fellow. No one
was so thoughtful of mother, and no one ever loved me so much as
Brother Tom. Nothing was too much trouble for him to do for others,
and if he had let those wild fellows alone, he would have been all
right.” Lettice’s eyes were full of tears again, but this time they were
not tears of anger.
Her aunt viewed her with a puzzled smile. “How you do fly from one
thing to another, child. One minute you are in a rage, and the next
you are melted to tears of sorrow. Come, give that fantasy no more
thought. Run down and tell Mrs. Flynn that she must not let that
barrel of oysters go to waste, even if we have them three times a
day. We have such a little family now that it is hard to dispose of
things, but with prices so high, there is need of economy.” She
sighed as she spoke, and Lettice, who had been planning an excuse
to get back to the country, felt conscience-smitten, and would not
suggest such a thing, now that she realized how utterly alone her
aunt would be.
It was very dull for her in the quiet house, and Mrs. Hopkins would
not allow her to have even Lutie. She endured Danny, to be sure,
because his master had a fondness for the little fellow, and,
moreover, he made himself useful in many ways. But Lettice spent a
tedious winter, and though she tried to be patient, and did enjoy a
few frolics, she was glad to see the first signs of spring.
All through the winter had come cheering reports of naval victories of
more or less importance. Many prizes had been brought in by the
Baltimore privateers and letters-of-marque, for this city took the lead
in sending out such vessels. From the port of New York came the
news that Joseph had been successful in capturing more than one
English vessel, and had taken them into the Northern ports. Thirteen
merchant vessels were captured off the coast of Spain by one
Baltimore ship alone, and this record was equalled by more than one
gallant cruiser. Not a day passed but news arrived of some valiant
sea-fight. In February Bainbridge took the Java. In March the Hornet
worsted the Peacock, and the names of Hull and Decatur,
Bainbridge and Jones, were on every one’s lips. Throughout all this
naval warfare Baltimore was foremost in energetically showing fight,
and against the state of Maryland, in consequence, the strongest
enmity of the foe seemed to be directed.
It was in April that Rhoda and her father announced that they would
return to Baltimore, and then Lettice saw that her desire to go home
could be granted, and she wrote to her brother James to come for
her. James, nothing loath, responded at once, so that he arrived in
time to welcome Rhoda. Under her father’s watchful eye Rhoda was
not very demonstrative in her greetings, and Mr. Clinton, following
close in her wake, was not received with much enthusiasm by Lettice
—a fact he was not slow to notice and to comment upon.
“I am coming down to Sylvia’s Ramble again,” he whispered to
Lettice.
“When Rhoda comes, I suppose,” Lettice returned in chilling tones.
“Don’t be jealous,” Mr. Clinton begged.
Lettice turned upon him with scornful eyes. “Jealous! I jealous? You
are vastly mistaken, sir!” and not another word did she vouchsafe
him the remainder of the day.
The next morning early she and James started down the bay on one
of the packets running from Baltimore to Queenstown. It did not
seem possible to those whose plantations lay along the inland
creeks that the enemy could have any object in penetrating into their
part of the country; yet at that very time the British were ravaging the
southern shores of the Chesapeake, plundering plantations, and
carrying off not only slaves and household valuables, but even
robbing women and children of their clothing. In spite of their straits
but little protection was given them by the government—this partly
because it was not able—and the unfortunate inhabitants had to
protect themselves as best they could.
On the morning that Lettice and her brother departed there were
lively preparations going on in the city of Baltimore. Lookout boats
were established far down the river; troops were stationed along the
shores, for the news had come that the enemy was approaching,
and that Baltimore was to be the object of attack.
Mrs. Hopkins and the newly arrived visitors absolutely refused to
venture down the bay. “We will escape in another direction, if need
be,” they said.
“You mean you will stay to welcome your friends, the British,” Lettice
said saucily. “That’s not what I will do. If we are to meet them, let it
be in our own home.”
“Pray, Miss Lettice,” Mr. Clinton said, “remain with us. We will have
the means to protect you and your brother—a means which may be
lacking when you pass beyond our influence.”
Lettice shot him a withering glance. “Your protection, indeed! I’d
rather die than be indebted to your complaisance for my safety!” And
those ever ready and passionate tears began to gather in her eyes.
Rhoda made a slight movement toward her, but her father laid his
hand on her arm and she passed, pressing her lips tightly together.
Lettice gave a toss of her head, and said, “Come, Brother James, it
is time we were off; the packet will be starting without us.”
“I most devoutly wish it would!” Mr. Clinton exclaimed.
“Well, it won’t!” Lettice retorted, moving toward the door. “Come,
James, cut short your adieux. Good-by, all of you. I leave you to the
tender mercies of Admiral Cockburn.” And without a turn of her head
she hastened down the street.
James followed and overtook her at the corner. “You are a spoiled
little minx, Letty,” he said. “Why do you speak so disrespectfully to
your elders?”
“Do you perchance mean Robert Clinton? Am I to have such an
inordinate amount of consideration for him because of his advantage
of a few years?”
“Oh, Robert Clinton, was it? But you included Mr. Kendall and Aunt
Martha in your remarks.”
“Well, if I did, I am glad; I’d not have had the temerity to attack them
but that I was so hot against that weathercock.”
“Weathercock, is it? Humph!” James was silent a moment, and then
he added, “Weathercocks seem to be a product of New England.”
“Are they then male and female?” Lettice asked mischievously. Then
seeing her brother’s face looked really grave and troubled, she
linked her arm in his and said coaxingly: “Never mind, Jamie, there
are as good fish in the sea as ever yet were caught, and one doesn’t
need to go so far from home for them. Let’s whistle these weather-
vanes off, and let them whirl to the tune their north wind blows. Is
that the Patapsco? I’m glad to be aboard her once more. There
seems to be a fair number of passengers in spite of the alarms. We
will have a right merry time, I reckon. There is Becky Lowe, as I live!
and Tyler Baldwin, and—Come, Jamie, help me up.” And in a few
minutes a jolly little party was established in one corner of the boat,
Lettice and her brother being welcomed heartily.
“I’m scared to death!” Becky cried. “Jamie, I was so relieved to see
you come aboard; it guarantees one more protector if we are
attacked by the British. You will fight for me, won’t you?” And she
turned a coquettish glance upon him, moving a little aside that he
might take a seat next her.
Lettice, leaning over the rail, watched the water as the boat moved
out of her dock and started down the Basin, moving slowly between
the shores now showing their first suggestion of spring.
“Are you scared, Miss Lettice?” asked Tyler Baldwin by her side.
“No, are you?” she asked, without raising her eyes.
“Yes, for you.”
Lettice looked up, startled. “What do you mean?”
“I mean that I wish to heaven that all the ladies were safe inland,
miles from the coast. I’ve no confidence in our being safe, although
the captain says so.”
“What would they do to us if they were to take us?” asked Lettice,
looking sober.
“They’d not treat you ill, I hope, but they might scare you to death.
Miss Lettice, I have not seen you since your visit to Washington. Did
you enjoy the naval ball?”
“You are changing the subject. Do I look pale with fright?”
“No, you do not; but it is not a pleasant thing to anticipate, and I
should not have spoken of it. Why harrow ourselves with what may
not happen at all?”
“Why, indeed. Yes, I was at the ball. How did you know?”
“I didn’t know, positively; I promised to find out. I judged from the
description given me by one who saw you that it might be you whom
my cousin, Ellicott Baldwin, met.”
“Is he a naval officer? A young man? Yes, I see, it is you of whom he
reminded me. Did he tell you—Oh, Tyler, I hope he didn’t think me a
forward piece. I spoke to him in a moment of excitement, not
realizing that he was a stranger. How came he to mention it?”
“He was most desirous of discovering who you were. He could not
learn your name, and the best he could do was to find out the names
of your companions. When he told me who they were, and described
you, I was able to tell him that I was almost certain that the lady of
his fancy was none other than Miss Lettice Hopkins, of Queen
Anne’s County. Do not trouble yourself over having met him in so
chance a way; he has only admiration for you, and spoke of you in a
most respectful manner. He told me of your meeting, and some day
—Heavens! what is that?”
They both started up, for the boat was now opposite North Point, and
they saw bearing down upon them several small vessels belonging
to the enemy’s squadron which lay just within the mouth of the river.
Soon followed a scene of confusion. Becky Lowe fell fainting into
James’s arms. Lettice, with pale face and imploring eyes, clung
close to Tyler Baldwin. “What will they do?” she whispered. “Shall
you have to fight?”
“It would do little good, and so I think the captain will conclude. In
such a case discretion is the better part of valor. The captain, for the
sake of all concerned, will probably submit with the best grace he
can summon. We are not prepared for a battle.” And the event
proved the truth of his words.
“We are prisoners,” said Tyler, after returning to her from a tour of
investigation. “All we have to do is to make the best of it. They are
preparing to put us under guard, and are helping themselves to
whatever they can find.”
Becky had recovered sufficiently to sit sobbing by James’s side. He
was trying to comfort her, and looked pleadingly at his sister, that she
might understand that her assistance would be appreciated.
“Come, Becky,” said Lettice, in quiet tones, “there is no use fussing
over the matter. We may be thankful that we are not hurt, and that
there is not going to be any fighting. I think we should submit with
dignity, and show them what stuff American girls are made of.” But
Becky was not to be comforted at once and continued weeping
hysterically.
“Law, Becky,” Lettice said, at last out of patience, “you fairly provoke
me. What is the use of your snivelling and sniffling? There is nothing
to be gained by it, and you only draw attention to yourself; that is
what you want, I shall believe, if you don’t stop. Look at Sally Weeks,
she is as still as a mouse.” Nevertheless, in spite of any effort to
make light of the situation, it was a hard ordeal for them all; for
instead of reaching their homes that evening, as they had expected,
they were all night under guard, and the next morning saw a wan
and weary company.
“How much longer shall we be kept here?” Lettice asked her brother,
wistfully. But the answer came with the order to remove the prisoners
to an old boat. “You are allowed a permit from the admiral to proceed
to Queenstown,” they were told, and they did not dare to resent the
impertinence of the message.
It was a long and uncomfortable trip which was before them; for with
scarcely any food, and with no water at all, after their night of
detention, and upon a miserable hulk of a boat, which made but slow
progress, it was as forlorn a company as one might wish to see,
which at last landed at Queenstown in Chester River. But the effect
of this was that not one of the party but felt that when the moment
came, he or she would do the utmost to work revenge.
CHAPTER VIII.
First Blood.
“Cockburn is coming!” This was the news that was borne from lip to
lip, and Lettice was made to repeat her experience over and over. It
must be said that she did rather needlessly enlarge upon the terrors
of the occasion when Lutie was the listener, and the eyes of that
sable maiden grew bigger and bigger as Lettice described Admiral
Cockburn’s appearance: a great big man, as tall as a locust tree,
with fiery red hair and blazing eyes and a long beard that blew out
like the tail of a comet; so he appeared to Lutie’s vision, her
imagination adding hoofs and horns; and he became the theme of
Jubal’s perorations, taking the place of “Poly Bonypart” as a
bugaboo to scare the children and the more timid girls. And not
without reason; for a terrifying account of a raid upon Havre-de-
Grâce and other towns in the upper Chesapeake was cause enough
for alarm.
It was Birket Dean who came galloping over with news: “Cockburn,
with a big force of men, has been playing havoc up in Kent and Cecil
counties, and even beyond. Havre-de-Grâce has suffered; every one
has been plundered, and the ravagers weren’t satisfied with that, but
went up the Sassafras and destroyed Fredericktown and
Georgetown. They say that the women pleaded and begged that he
would spare their homes, but he refused, and the houses were
burned to the ground; and he says he’ll not be satisfied till he has
burned every building in Baltimore.”
“Oh, does he mean to go there next?” Lettice asked in excitement.
“They say he doubtless did intend to, but he has heard through his
friends among the Peace men that the lookout boats are stationed all
the way down the Patapsco, and that there are videttes along the
shores of the bay and the river, and besides, the City Brigade will be
ready for them. They fired alarm guns in Baltimore and had all the
troops out, but the redcoats passed by Annapolis and Baltimore and
went to the upper bay. A great many people moved out of the city, I
am told.”
“Do you suppose there can really be any danger of their coming
here?” Betty asked, holding her baby very closely.
The men looked at each other and were silent, then William,
caressing the top of his little son’s silky head, said, “If they do, we’ll
defend our homes to the last drop of blood.”
“And you’ll not leave us, William?” said Betty, scanning his face
eagerly.
“My place is near home, I have determined,” he replied, smiling
down at her.
The next few days brought tales of further marauding; tales of such
horror that Betty and Lettice clung to each other in terror. And,
indeed, the atrocities committed were such that in some places the
word “Hampton” was used instead of “Attention” to call the men to
order, and the accounts of the terrible ravages lessened greatly the
number of those who opposed the war.
But as days went by and no Cockburn appeared, the fears even of
those most easily frightened were quelled, and affairs went on as
usual.
“It’s desperately tiresome, this staying at home,” Lettice said to her
brother James. “I don’t mean to do it any longer. Would there be any
harm, do you think, in our going out for a wee bit of a way on the
water? We know full well that the British are away down the bay, and
I haven’t had a sail this many a day. Do take me out, Jamie, or I’ll go
alone.” It was a lovely morning in July, somewhat warm, and
promising greater heat. Lettice sat discontentedly on the lower step
of the porch, looking off toward the creek.
“You’ll not go alone,” said James, swinging his long legs over the
railing of the porch, and sitting down beside her.
“Then you’ll take me.”
“Yes; there’s not a sail in sight, and I reckon we’ll have it all to
ourselves, besides—”
“Besides what?”
“I think I’d like to be at Queenstown when the boat comes in.”
Lettice turned and looked at him. “Why? You have a reason. I see it
in your eyes.”
“So I have.” He took a letter from his pocket and held it off at a little
distance. Lettice made a grab for it, but he caught her hand, and
laughing, held her firmly. “It isn’t for you,” he said.
“Whose is it, then?”
“Mine.”
“Let me see the handwriting. Please do, Jamie.”
He held the letter at a careful distance, and she read the address in
Rhoda’s neat hand: Mr. James Hopkins. “From Rhoda! Oh, is she
coming down on the packet?”
“Yes, so the letter says, and will I meet her and Aunt Martha. It
seems that Aunt Martha has been ill, and the city is hot, so she
thinks she may venture down to this neighborhood; unwisely, I think,
with the enemy so near and ready to pounce on us at any moment.”
“Now, James, quit talking so to scare me. And where is Rhoda’s
devoted cavalier, that she must call on you for an escort?”
“I do not know where he is; her father has gone to Philadelphia, and
probably the young man is there too; they seem to travel in
company.”
“I wonder if they went on the new steamboat. I should think they
would go that way; such a novelty as it is.”
“Perhaps they did; Rhoda does not say.”
“Well come, then; if we are to meet the packet, we ought to be off. I
hope there will be news from father. It seems a long time between
letters, and so very long since we have seen him. I think I will take
Lutie along with me, and we can stay all night at Sylvia’s Ramble. I’ll

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 inda R. Littlejohns, MSN, RN, CNRN, SCRN, FAAN

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I wish to acknowledge the American Association of Neuroscience Nurses

1 Neurological Assessment of the Neonate,

15 Infections of the Central Nervous System����������������������������������� 515

Jennifer A. Disabato and Dee A. Daniels

1.1 Introduction secondary complications that can further impede

© Springer International Publishing AG 2017 1

Table 1.1 Neurological diagnostic and imaging modalities

Table 1.1 (continued)

1.2.1 Developmental Assessment prehensive developmental approach in the hospi-

Table 1.3 Interpreting the neurological examination in the neonate/infant

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