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IV
Special Issues in the Hospital Setting
11. Decisional Capacity
12. Nonadherence
13. Pain
14. End-of-Life Issues

V
Ethics and Professional Issues
15. The Ethics of Consultation With Medical Inpatients
16. Training, Billing, and Other Professional Issues

APPENDIX A

APPENDIX B

REFERENCES

ABOUT THE AUTHOR

8
Acknowledgments

Thanks to the many patients who have shared their struggles and successes
as they navigated their way through difficult medical and psychological
problems. Thanks also to my students and colleagues for helping me
collect and articulate my thoughts about this work. Finally, special thanks
and love to my parents, Arlene and Robert Labott, for everything.

9
10
P sychological practice in the inpatient medical setting is different in
many ways from both outpatient clinical work and inpatient work in a
psychiatric unit. Yet psychology trainees usually begin their first clinical
placement in a hospital without any guidance or coursework on how to
work in that setting. The same is true of established clinicians who have
not specialized in health psychology. Although supervisors usually have a
good grasp of the relevant issues, there is never enough time to sit with
every trainee or to run a basic seminar on hospital work before the trainee
begins.
This book seeks to provide basic information on clinical and
professional issues operative in the inpatient medical setting for
individuals who already have skills in general clinical psychology but who
have little experience in a hospital. It addresses clinical questions, such as
the following:
What is delirium and how do I treat it?
How do I treat anxiety that is directly caused by medication,
rather than due to psychological concerns?
The book also addresses ethical questions, such as the following:

11
 What if a patient refuses to be seen?
How do I maintain confidentiality when I am working with a
large medical team?
It addresses professional issues, such as the following:
How do I handle a patient’s death?
What do I do if I am evaluating a patient and another
provider also wants to see the patient?
It answers basic questions regarding consultation, including the
following:
How do I understand the medical information in the patient’s
chart?
What should my report look like, and where does it go?
This book provides detailed instruction on matters of significance
when working in a hospital, including interpretation of the medical record,
description of major psychological problems that occur in the hospital, and
conducting assessment and treatment in this setting. It also provides
information on attending to particular patient needs in the hospital setting,
such as evaluating decisional capacity and helping them deal with end-of-
life issues.
The theoretical approach of this book follows the biopsychosocial
model, the current standard of practice in clinical health psychology. In
this model, the biological, social, and psychological dimensions of illness
are all considered when developing a conceptualization of the patient and
his or her illness. The interventions described for use with medical
inpatients are based largely on cognitive–behavioral, evidence-based
approaches. For some of the thorny questions in this book, there is no
empirical literature; these are discussed from a practical perspective based
on the author’s many years of clinical experience in this setting.
The book is divided into five parts. Part I focuses on the hospital
setting and inpatient consultation models. Chapter 1 explains the structure
of hospital units and the hierarchy of medical teams, as well as relevant
hospital standards, including credentials and privileges. Differences
between hospital and outpatient practice are discussed, as well as

12
documentation and infection control procedures. Chapter 2 describes the
biopsychosocial model—the foundation of inpatient health psychology
consultation—as well as various types of consultations and consultation
services in which a psychologist can work.
Part II addresses the nuts and bolts of performing an inpatient
consultation. Chapter 3 describes background preparation before seeing
the patient and includes information on understanding the referral,
interpreting the medical record, and generating specific topics to be
addressed in the interview with the patient. Chapter 4 describes the patient
interview and includes tips on getting it started, specific content to cover,
common problems in conducting inpatient interviews, and providing
feedback to the patient. Chapter 5 discusses gathering collateral
information, integrating data, and providing written and verbal reports to
the patient’s medical providers.
Part III addresses common psychological issues in the hospital setting.
Chapter 6 defines and describes adjustment problems faced by hospitalized
patients and describes theories of adjustment, relevant tasks and
interventions to aid adjustment, and factors that can influence adjustment.
Chapter 7 addresses anxiety and describes etiologies of anxiety that can
occur in the hospital, such as premorbid anxiety, new anxiety due to the
current medical situation, medical disorders that can present with anxiety,
and anxiety symptoms caused by medications. Treatments to address
anxiety are presented, including education, medication, and cognitive–
behavioral interventions. Chapter 8 addresses depression and includes a
description of its various etiologies, including premorbid depression, new-
onset depression secondary to a medical problem, medical disorders
associated with depression, and depression due to medication. Suicide in
hospitalized patients is discussed, as are relevant risk factors. Interventions
to address depression and depressed mood are described and include
education, cognitive–behavioral strategies, social support, and
psychotropic medication. Chapter 9 defines delirium, its clinical features,
and its causes. Means to assess and diagnose delirium are described,
together with strategies for the management of delirious patients. Chapter
10 focuses on substance use and abuse and begins with a description of
referrals for substance use. The prevalence and impacts of illicit and

13
prescription drug use are presented, as well as assessment strategies.
Psychological treatments for drug and alcohol overuse are then delineated.
Part IV is focused on special issues in the hospital, that is, those
occurring frequently in the hospital but less often in the outpatient setting.
Chapter 11 addresses decisional capacity and describes referrals, criteria
for capacity, the evaluation to determine capacity, and implications if the
patient lacks decisional capacity. Chapter 12 deals with nonadherence to
medical recommendations and outlines the implications of nonadherence
and relevant theoretical models. Factors that influence adherence are
presented, as are strategies to establish initial adherence, evaluate
adherence problems, and interventions to address nonadherence. Chapter
13 is focused on pain and includes sections on assessment, factors that
affect pain, and psychological interventions to decrease pain. Chapter 14
deals with end-of-life issues. It includes details about the primary concerns
of dying patients, advance directives, death with dignity legislation, and
steps the psychologist can take to promote a good death.
Part V focuses on ethics and professional issues. Chapter 15 discusses
ethical issues that are especially relevant in the hospital, such as
confidentiality, respect for other professionals, and culture and diversity
issues. Chapter 16 provides guidance for training students in the hospital
setting, as well as billing matters. Developing a professional identity,
caring for oneself, marketing inpatient psychology services, and other
professional challenges are also discussed.
My perspective on health psychology inpatient work is derived from a
university-based medical center, but the information and examples are also
applicable for consultants working in nonacademic hospitals. The cases
and medical record samples are based on real patients and provider notes,
but identifying information has been altered to protect patient privacy.
Throughout the book, I have made some patients and providers male and
others female to avoid the cumbersome use of “he or she.”

14
15
P roviding psychological services in an inpatient medical setting can be
intimidating to those who have not previously worked in a hospital. The
pace can be fast, the logistics of seeing patients are different from the
outpatient setting, and most patients have not requested any psychological
evaluation or treatment. There are also rules and norms to be followed that
may be wholly unfamiliar to professionals who have worked exclusively in
outpatient settings. An understanding of the structure and expectations of
the hospital setting will facilitate the health psychology consultant’s work
and also enhance her reputation among medical colleagues. These topics
are described more fully in this chapter.

Hospital Units, Medical Teams, and the Health

Psychology Consultant
Most hospitals are separated into at least some specialized units. Even
small hospitals may have specialized obstetrics, pediatric, and intensive
care units (ICUs). The larger the hospital, the more specialized units there
are likely to be, with certain floors dedicated to patients with specific
medical needs, such as cardiology, general medicine, oncology, or

16
orthopedics. Some hospitals may even have specialized ICUs, for example,
for cardiology, neurosurgery, or transplant. When a referral is received, the
location of the patient may provide a clue to the patient’s main medical
issue. At times, however, floor assignment is a result of bed availability.
In teaching hospitals, patients are treated by teams of physicians.
These teams are headed by the attending physician (referred to as the
attending), who is a faculty member in the medical school and is involved
in teaching, supervision, research, and patient care activities. The attending
is ultimately responsible for the patient’s care, although much of the actual
treatment is performed by other members of the team. There is often a
fellow, who has completed his medical residency and is now completing
specialty training (such as in emergency medicine, cardiology, or
pulmonary disease), usually for 2 to 3 years. The treatment team may also
include one or more medical residents. Residents have finished medical
school and are working on their medical residency, which is required
before becoming an independent practitioner. They are sometimes referred
to as house staff because they manage all patient care under the
supervision of the attending. Residents work long hours because they are
frequently on call, spending many sleepless nights in the hospital dealing
with emergent medical issues. There may also be medical students on the
team who are currently in medical school and have little experience in
patient care. One motto of medical training is “see one, do one, teach one”;
in practice, this means the individuals on the treatment team who are
providing patient care will have varying levels of experience in
interviewing, performing medical procedures, and negotiating the hospital
system.
Members of the primary medical treatment team will see the patient
each day to evaluate the patient’s progress and to perform procedures. The
entire team will round together once daily, visiting all of the patients for
whom they are responsible. During rounds, members of the team describe
the patient’s status, plans are made regarding next steps in the treatment,
and the attending provides supervision. If the health psychology consultant
is present at the time of the primary team’s rounds, it is useful to listen to
the team’s discussion of the patient as well as their meeting with the
patient, if appropriate. This will provide the psychologist with details

17
about the treatment issues and the team’s decision-making about them, as
well as an opportunity to observe interaction patterns between the patient
and his medical providers. Rounds may also provide a forum for the health
psychology consultant to update the team about the psychological issues
and the psychological treatment plan. Although it may perhaps be anxiety
provoking initially, the psychologist should be prepared to address
questions from the treatment team any time they are encountered; this is a
good opportunity for the health psychologist to provide relevant
information and to demonstrate his usefulness to the medical team and the
patient.
All members of the primary medical team rotate on and off, and not
all on the same schedule; for example, the attending may be “on service”
(which means he is leading a team in the hospital) for a month, whereas
the fellow and residents may be on the team for several months, under the
supervision of different attendings. The primary treatment team is assigned
certain patients; for example, the cardiology team will see patients
admitted for cardiac problems. In a large hospital, many of these patients
will be located in one unit. If a patient from a cardiology unit is transferred
to the ICU, the cardiology team will likely follow (i.e., continue to treat)
the patient there, although the ICU medical team may take primary
responsibility while the patient is in the ICU. In most cases, a health
psychology consultant who is following a patient will continue to treat that
patient if she moves to a different unit. An exception to this is if the new
unit has other psychological services available, for example, if a
cardiology patient is transferred to a psychiatry unit after she is stable
medically. In that case, the health psychology consultant would ensure
continuity of care, while transferring the patient to a new mental health
provider located on that unit. The health psychology consultant could
continue to see the patient if he has been working with the patient on a
specific issue that cannot be readily managed by a provider on the new
unit (e.g., if teaching specific imagery techniques for pain management, if
there are no mental health providers on the new unit with expertise in this
area).
Because most of the day-to-day care of the patient is provided by the
fellows and residents, these are the people with whom the health

18
psychology consultant will interact most often. They will typically order
consultations, including those for health psychology, and are usually the
contact person for providing feedback after the patient has been seen.
Nonacademic hospitals, including large community medical centers
and small community hospitals, are staffed differently. Here, doctors who
are private practitioners may see their own outpatients when they are
admitted to the hospital. In these settings, the attending is the senior
physician who is assigned to the case and who will “follow” (i.e., treat) the
patient while she is in the hospital. In the nonacademic hospital setting,
there is generally no team of fellows, residents, and medical students.
Nurses are a great source of information for the health psychology
consultant. They are generally updated on the most recent changes in the
patient’s situation and are aware of issues that have not yet made it into the
patient’s medical record. Many nurses treat the same patients day after day
and have spent a significant amount of time with them. They are usually
good listeners and have had ample time to observe the patient. Patients
often confide in their nurses, making them privy to information that others
are unaware of. They may be aware of family and social dynamics from
observing patients with their visitors. Nurses are on the front line for
management of a patient’s behavior and safety, for example, in the case of
a patient who is delirious or aggressive. Not only will a nurse be able to
describe the patient’s behavior in detail, she may also be able to compare
the patient’s current status with his baseline behavior and cognition, aiding
the psychologist in making the correct diagnosis. In certain units of a
hospital, nurse practitioners may be allowed to prescribe medication and
may be the main point of contact with the medical team for the psychology
consultant.
Most hospital units also have a dedicated ward clerk who answers
telephones, locates nurses and patients, pages staff, directs visitors, and
handles many other tasks to keep the unit running efficiently. Ward clerks
know who is responsible for what on the unit and how to find everyone;
they can provide much helpful information to the health psychology
consultant, especially on an unfamiliar unit or when the relevant providers
are unknown.
Unless there has previously been a strong health psychology presence

19
in the hospital, medical personnel may not have a clear idea of who a
health psychology consultant is and what he has to offer to the patients and
medical staff, so the health psychology consultant will need to educate
others about his role. This is done by explicitly telling others what the role
of the health psychologist is, as well as by demonstrating it through patient
treatment and liaison with medical teams. This education sometimes
involves contrasting the work of the health psychology consultant with
someone whose role the medical team already understands, such as that of
the psychiatrist or the social worker.
One of the best ways to educate others about the role of the health
psychology consultant is to describe our work to them as we provide
feedback on a particular patient. That is, providing a brief
conceptualization of the patient’s problem and our treatment plan can
show the primary medical team how we think about patients and what we
can do to help (see Exhibit 1.1).

EXHIBIT 1.1
Describing the Consulting Psychologist’s Role on the Health Team
“You asked us to see Ms. X because she is crying and seems anxious. She is
anxious—she has never really been sick before, and she is scared about what
her test results will show. Also, her husband died in this hospital about 2 years
ago, and being back here has stirred up a lot of emotions for her. We are
teaching her ways to manage her anxiety and she is doing well with that. We
are also working with her to manage her grief, and will provide outpatient
grief therapy referrals if she needs that when she is ready for discharge.”

At times, the psychologist’s response to a referral question will help

the members of the medical team do their work (e.g., in an assessment of a
patient’s decisional capacity). If a patient is refusing treatment, the
psychologist’s conclusion about the patient’s decisional capacity will
allow the medical team to determine what their next steps should be. In
other cases, making plans to help the medical team manage a difficult
patient can make the patient’s treatment easier and will demonstrate ways
in which the health psychology consultant can help them with the

20
management of patient behavior. The brief script in Exhibit 1.2
demonstrates how the health psychology consultant can work with the
medical team to manage a patient’s behavior.

EXHIBIT 1.2
Explaining How the Health Psychologist Can Help Manage a Patient’s
Behavior
“Ms. Y has been calling at all hours with additional questions that you have
already answered for her. She is anxious, and does better when she has
information, but she has a poor memory, so she does not recall what you have
told her, and so she asks again and again. We are working on some
organizational strategies with her and suggested that she write down her
questions as well as the answers you provide. We have also encouraged her
not to call you each time she has a question but to save her questions for
morning rounds. We have also arranged to have the patient’s daughter come
each morning, so that she is present when you round. She will help the patient
make notes and will also remind the patient if she forgets things that you told
her. We will also plan to see the patient later each day to help her review and
process the information you have given her and to teach her additional anxiety
management techniques.”

Once the medical providers understand the role of the health

psychology consultant, they can be encouraged to inform patients when a
health psychology consultation is being ordered so that patients are not
surprised when the consultant arrives. This is best done by describing a
team approach to patient care and the role of the health psychology
consultant in helping patients to manage the stress of medical illness,
rather than by describing the consultation in terms of mental illness.

Credentials, Privileges, and Medical Staff

Membership
Like any other provider in a hospital, a health psychology consultant
should always wear appropriate medical center identification. To practice

21
in a hospital, the health psychology consultant must be certified by the
hospital as a qualified professional who provides certain defined services.
Credentialing refers to the process in which a provider’s credentials (i.e.,
education, licensure, and training) are reviewed by a hospital board to
determine that the psychologist meets required criteria to provide
psychological services. All providers in the hospital are subject to this
process. Once credentialed, there is typically a review to recredential the
provider every few years. This recredentialing process may involve a
review of the provider’s work and may include a review of reports in the
medical record—both for content and timeliness—and also letters of
support from colleagues.
Privileges refer to the specific services that a credentialed provider is
allowed to perform in the hospital. These are requested by the provider,
then approved (or not) by a review board. These privileges are typically
also revisited every few years and adjusted as needed. The process is the
same for other medical providers; for example, an oncologist may have
privileges for ordering chemotherapy, performing biopsies, and infusing
stem cells but would not be approved to do psychotherapy or
neuropsychological assessment. Hospitals vary in the number of privileges
available to providers and the detail with which these privileges are
defined. That is, a small hospital may allow psychologists to provide
inpatient psychological services, outpatient psychological services, or
both. In other places, privileges for psychologists may be further
differentiated into inpatient psychological services that include
consultation, group therapy, pediatric treatment, or neuropsychological
assessment. The psychologist requests the privileges based on his training,
experience, and expected practice and then must practice within these
categories of privileges until other privileges are requested and granted.
See Robiner, Dixon, Miner, and Hong (2010) for a detailed discussion of
privileges for psychologists who work in hospitals
Physicians in hospitals are members of the medical staff, typically pay
dues to belong, and are involved in governance of the institution and their
profession. Depending on the setting, psychologists may or may not be full
voting members of the medical staff and may be designated as an affiliate
or some other category of membership that has fewer rights and

22
responsibilities. To the extent that psychologists can be involved in the
workings of the medical staff, they can provide input on issues that will
affect the practice of psychology in the hospital, consistent with American
Psychological Association (2013) guidelines.

Practical Issues When Treating Medical

Inpatients
Some of the practical issues to consider when consulting as part of a
medical team include reframing one’s professional role and relationship
with patients, understanding the pace and workflow in a hospital, and
quickly internalizing procedures and expectations with regard to infection
and documentation.

OUTPATIENT PROVIDER VERSUS PSYCHOLOGICAL

CONSULTANT
Many psychologists have experience as an independent provider in an
office or clinic setting, consulting with other providers as needed. In the
hospital setting, the health psychologist may perform evaluation and
intervention, but in the role of a consultant, a role that is somewhat
different from that of an independent provider. The consultant works with
the primary medical team, but the patient belongs to them, not to the
consultant. The psychological treatment should always be coordinated
with the medical treatment and should not interfere with it in any way.
Some patients will need intense psychological treatment, but much of that
may need to be postponed until the patient is an outpatient. The priority in
the hospital is the medical treatment, and although the psychological
treatment can be an important part of that, it is secondary to the medical
treatment. The health psychology consultant provides feedback to the
primary treatment team, which in turn makes the overall decisions on the
patient’s care. Specifically, this means that the health psychology
consultant would typically not write orders for the patient but would make
recommendations to the treatment team, such as for neuropsychological

23
testing, physical therapy, or a psychiatry evaluation that the primary
treatment team can then choose to follow or not.
It is important to be accessible to the primary treatment team, so that
they can contact the health psychology consultant with any questions they
have about the patient’s psychological care; this is especially relevant as
the patient nears discharge and plans for any outpatient psychological
follow-up need to be made. In the outpatient setting, returning a telephone
call within 24 hours is often acceptable. In the inpatient setting, however,
pages or texts need to be returned within a few minutes because the
hospital setting has a faster pace than the outpatient setting, and decisions
need to be made and implemented more quickly.

INPATIENTS GENERALLY DO NOT REQUEST

SERVICES
Most psychologists have experience with clients who make an
appointment and come to the office, seeking help with a specific
presenting problem. Those clients choose to seek mental health services
and are motivated to achieve some outcome that they desire. In the
medical inpatient setting, this is typically not the case. Patients rarely ask
to be seen for a psychological evaluation; instead, one of their medical
providers deems the psychological consultation necessary and orders it.
Patients may not know what a health psychology evaluation involves or
feel that it is warranted, nor are they always even aware that the
consultation has been requested for them. In these cases, then, the visit by
the health psychology consultant is a surprise to the patient. The reason for
the visit should be described to patients so that they have an idea of what
to expect because many have never seen a mental health professional
before. Providing a general idea of what the consultation is about will help
patients adhere to the treatment plan and increase their comfort with the
interview (see Chapter 4, this volume, for more detail on explaining this to
patients).

SCHEDULING, WORKFLOW, AND PACE

Most inpatient work is not scheduled as an outpatient visit is, that is, with

24
an appointment at a particular time on a specific date, although there can
be exceptions. If a patient is very busy with appointments, such as on an
acute rehabilitation unit where several hours of physical therapy and
occupational therapy are required daily, it may be possible to informally
schedule an appointment, usually with the patient’s nurse, to be sure you
are able to see the patient on a certain day. Flexibility is important, as other
activities may still interfere. More commonly, medical professionals have
a list of patients they need to see on a particular day, and they circulate
around the hospital until all the work is completed. The most urgent issues
need to be prioritized. One implication of this system is that several people
from different services (e.g., health psychology, neurology, infectious
disease) may need to see the same patient and will need to work around
each other so that they can all get their work done. If a patient is newly
admitted or if new medical issues have developed, there may be a host of
people who need to see and evaluate the patient in a short amount of time.
For example, if a patient was admitted with a fall and possible stroke, the
primary service may request consultations with orthopedics, neurology,
physical therapy, and health psychology all on the same day. Each of these
consultants typically has 24 hours to complete the evaluation and provide
recommendations to the primary medical team. All of these providers will
come and go throughout the day, making it very busy for patients at times.
The system dictates that providers will need to work around each other
to get all the work done. There are unwritten rules about how this works,
and the individual consultants need to work this out on a case-by-case
basis. The main issue that dictates which service has priority is the
importance of the information to be gained from the evaluation provided
by that specialty area. For example, in the preceding case, a neurological
evaluation is necessary to determine whether the patient has had a stroke
and what treatment is warranted. Although the health psychology
evaluation will be important to the patient’s overall coping and adjustment
with the medical condition, in the acute phase while the diagnosis is being
determined, the neurology consultation is more important. If the health
psychologist is in the process of an evaluation when the neurologist
arrives, a health psychologist who is a good team player will make plans to
return to finish the interview later so that the neurologist can complete her

25
evaluation in a timely manner.
Another variable that enters into this decision of whose work takes
precedence is the amount of time the provider needs to complete her
evaluation with the patient. The health psychology evaluation takes a lot of
time, relative to many of the medical interviews. Sometimes other
providers will only need to ask the patient a few basic questions to proceed
with their work. If the health psychology evaluation is underway and the
patient’s medical resident arrives to ask the patient a few questions about
his home medications (to be sure the orders for the inpatient admission are
properly written), it makes sense for the health psychologist either to step
aside and let the medical resident interrupt to get the information she needs
or step out of the room briefly and then continue the evaluation when the
resident is finished. The rules for whose visit takes priority may seem
vague, but common sense will help one figure out what to do in each
specific situation. Learning to negotiate this issue as a professional will be
important in the long term because the health psychology consultant will
meet the same people from other disciplines repeatedly in patient rooms,
and building collaborative relationships will pay off over time.
The amount of time spent with a hospitalized patient is variable and
depends on the work that the health psychologist needs to do with the
patient. For example, an initial evaluation will take longer than a follow-up
visit. It also depends on other factors in the hospital (e.g., the patient needs
to go for an ultrasound). Comprehensive initial evaluations can take an
hour or longer. Follow-up visits for treatment or monitoring could occur
daily for 10 to 20 minutes or might only occur every few days, depending
on the issues being addressed. Some patients may be followed for the
duration of their hospital stay, especially those who have difficulty coping
with a new diagnosis and treatment. Others may be seen only for a few
visits—for example, when assessing decisional capacity, especially if
nothing else needs to be addressed after the evaluation.
Because of the pace of the inpatient hospital setting, the health
psychology consultant needs to be able to access information quickly, to
be able to answer questions and make decisions about patient care
promptly. Exhibit 1.3 is a list of resources that will enable the psychologist
to function efficiently, while avoiding calls to others or trips to the library

26
to get necessary information. Some of these resources can be carried
electronically, and others will be on paper in a lab coat pocket or on a
clipboard.

EXHIBIT 1.3
Resources for the Health Psychology Consultation
Mental status examination questions
List of common medical abbreviations (see Chapter 3 and Appendix A)
Telephone and pager numbers for interpreters, social work, psychiatry on call
Frequently used outpatient psychology, psychiatry, and substance abuse
referrals
Consultation questions outline (see Chapter 4, Exhibit 4.1)
Psychiatric medications and standard doses
Causes of delirium
Pens and paper for notes and patient drawings
Information relevant to special settings (e.g., oncology drugs that cause
psychological side effects)

DOCUMENTATION
All interactions with patients must be documented in the patient’s medical
record. Placing notes in the medical record informs other members of the
treatment team about the work the psychologist is doing with the patient
and can facilitate coordinated care. Although patient care is the main
function of documentation, it is also necessary for legal and billing
purposes. Medical record documentation is generally concise, while
providing enough detail so that others can understand the content and
relevant details.
All providers regularly make decisions about what specific content to
place into the medical record. As a health psychology consultant, there are
times when less detail is desirable, such as when a patient provides
specific information regarding sexual abuse or marital conflicts. Health
psychology inpatient notes are not separated from the rest of the record as
outpatient psychology treatment notes may be, so if medical records are
requested for any reason, health psychology notes are sent out along with

27
the rest. Further, doctors, nurses, and many other providers in the hospital
have access to these notes. Therefore, consideration must be given to the
reporting of sensitive issues; specific and detailed information on issues
such as sexuality, abuse, and other potentially sensitive issues should be
avoided unless they are directly pertinent to the medical problem. For
example, if a patient reports detailed information on a spouse’s infidelities
and how this has affected her depression and noncompliance with medical
treatment, rather than providing details about the infidelity in the patient’s
medical record, the report could refer to “marital stressors” that played a
role in the patient’s emotional state and nonadherence. As Robinson and
Baker (2006) noted, “One simple rule of thumb is not to write anything in
the medical record that a psychologist does not want other people,
including the patient, to know” (p. 266). Although medical records are
confidential, there are still many people who could learn information from
the psychologist’s report that they do not need to know and that could
negatively influence their interactions with the patient.
A psychologist might not document a lesbian relationship if the
patient has adequate social support and the relationship is stable. Yet that
information could be relevant if the medical team is setting up
postdischarge care for the patient. Medical staff who are aware that she is
in a lesbian relationship can rephrase their typical questions about her
husband and his ability to help her after discharge.
There are times when explicit detail is absolutely necessary in the
medical record, such as when describing a patient’s risk for suicide. The
cardinal rule of documentation is that “if it wasn’t documented, it didn’t
happen.” Although certainly important for the patient’s care, detailed
documentation of the psychologist’s evaluation of suicide potential is
critical if litigation occurs later.
Notes and reports from the health psychology consultant may need to
follow a particular format, depending on the rules at a particular
institution, and there may also be rules about the placement of psychology
notes in the medical record, as well as specific information to include in
those notes, such as billing codes. If there is no specific format dictated by
the institution, initial evaluation reports can follow the format
demonstrated in Chapter 5. Follow-up notes would be shorter and would

28
generally focus on the specific issue for which the patient is being treated
(also see examples of these notes in Chapter 5). All notes should include
contact information for the health psychology consultant to facilitate
communication with other providers if they have questions or input on the
patient and his care.
Documentation on work done with hospitalized patients must be
completed promptly or it is not useful. For example, adding a report to the
medical record that describes the behavior of a delirious patient 24 hours
after the evaluation may be irrelevant because the patient’s presentation
may be completely different by then. Many medical centers have rules on
how quickly documentation needs to be finalized in the medical record.
Regardless of formal documentation, verbal feedback on initial evaluations
and serious issues should be promptly provided to the treatment team.

INFECTION CONTROL PROCEDURES

Standard precautions to control infection include handwashing; avoiding
touch; wearing gloves when contacting secretions, blood, and fluids; and
proper handling of sharps, spills, and medical equipment (World Health
Organization, 2002). These procedures are to be used with every patient in
the hospital, regardless of the patient’s diagnosis, to prevent transmission
of infection. For psychologists, because there is no expected contact with
blood or bodily fluids, standard precautions require handwashing before
and after seeing the patient. Proper handwashing is the single most
important behavior that providers can use to protect themselves and
patients from infection and involves washing hands thoroughly with soap
and water or with a hand disinfectant (usually located outside of patient
rooms).
Transmission-based precautions are put in place for cases in which
standard precautions are not sufficient to interrupt the spread of infection.
These are instituted for patients who have been diagnosed with specific
infections or an infection that is suspected but as yet undiagnosed. The
additional level of precaution is indicated with a sign near the patient’s
room. Contact precautions are a type of transmission-based precaution for
patients who have infections that can be transmitted to others, such as
vancomycin-resistant enterococcus (VRE), methicillin-resistant

29
Staphylococcus aureus (MRSA), and Clostridium difficile (C. diff).
Although it is possible that a healthy health care provider could contract
one of these infections from contact with the patient, it is more likely that
the provider will carry the infection to another patient who is less able to
resist the infection and who will then contract it. Contact isolation
procedures include wearing a gown and gloves, in addition to
handwashing before and after the interaction with the patient. The gown
and gloves are put on before entering the patient’s room and then removed
and left inside the patient’s room in the garbage after the visit (so that the
infection is not taken outside of the room). Even though a health
psychology consultant generally has no intention of touching any blood or
body fluids, and perhaps not even of touching the patient at all, these
procedures must be followed for two reasons: (a) a provider never knows
when a patient may become delirious, pull an IV line, vomit, bleed, or do a
variety of other things that would put the provider in unexpected contact
with bodily fluids; and (b) hospitals can get into serious trouble with
regard to their accreditation if someone is seen not following the
appropriate precautionary procedures.
Other organisms are transmitted by droplets in the air, such as
influenza and pertussis, and require droplet precautions. Transmission of
these organisms is most likely to occur when the patient is coughing or
sneezing or during access to mucous membranes, such as during a
bronchoscopy procedure. In addition to standard precautions, droplet
precautions include wearing a mask as a barrier so that the provider does
not inhale the droplets.
Airborne precautions are put in place for patients who have (or are
suspected of having) an organism that is transmitted through the air, such
as tuberculosis or measles. Organisms transmitted by air are made up of
small particles (much smaller than droplets) that remain suspended in the
air, and so special ventilation systems are used in the rooms of patients
who have organisms that can be transmitted in this way. In addition, the
provider must wear a specific type of respirator (mask), typically the N95
type. This is a more solid mask than that used for droplets, and it does not
allow the organisms in the air to pass through and be inhaled.
The respirator needs to be fitted yearly for each provider (called fit

30
testing), and the provider needs to know which size to use and also how to
adjust it properly for maximum effectiveness. Therefore, if a health
psychology consultant has not been fitted for this specific type of mask, he
is not able to enter the patient’s room. See Siegel, Rhinehart, Jackson,
Chiarello, and the Health Care Infection Control Practices Advisory
Committee (2007) for more information on transmission-based
precautions.
Neutropenic precautions are for patients whose immune system is
impaired, that is, they do not have sufficient neutrophils to protect
themselves from infection. A low neutrophil count can occur after
chemotherapy, during a stem cell transplant, and at other times.
Neutropenic precautions are sometimes referred to as reverse precautions
because the purpose is to protect the patient, rather than the provider.
During the time of neutropenia, the patient can contract infections and
even die from organisms that would pose no threat to a healthy person. In
the case of neutropenic precautions, providers wear a gown and gloves,
often a mask, and perhaps also booties over the shoes. Recall that in the
case of contact isolation, the gown and gloves are left inside the patient’s
room, but in the case of neutropenic precautions, these are worn out into
the hallway after the visit with the patient, and thrown away there, to avoid
the provider leaving any potentially dangerous organisms inside the
patient’s room.

PRACTICAL ISSUES REGARDING INFECTION

CONTROL PROCEDURES
Although many providers will shake hands with a patient when
introducing themselves, hand-shaking should be avoided for infection
control reasons. Some mental health providers will make a point of
shaking hands, especially with certain patients (e.g., someone newly
diagnosed with HIV) to indicate to the patient that they are not
stigmatized. However, given the risks to patients of infections that can be
transmitted by their providers, it is desirable for providers to demonstrate
respect for their patients in other ways.
If the health psychology consultant has a cold or other transmittable

31
infection, she should take additional precautions to protect patients—all
patients, regardless of neutropenic or other precautions that are in place.
This could include avoiding contact with the patient (e.g., call the patient
on the telephone rather than going in to the room or have a colleague cover
the patient’s treatment temporarily), keeping visits as short as possible, and
wearing a mask to avoid infecting the patient. Patients are appreciative
when providers take any and all measures available to protect them from
infection.
Following these precautions can be uncomfortable and cumbersome.
Many people, when wearing a mask for more than a few minutes, become
hot and feel faint. If that occurs, visits need to be kept short to avoid the
provider passing out in the patient’s room. Wearing gloves can make it
difficult to take notes, so it is usually easiest to skip notes when in the
patient’s room, do a briefer interview, and make notes when back outside
the room. If notes are warranted with a patient on transmission-based
precautions, the clipboard and pen need to be disinfected or thrown out,
and paper notes (e.g., patient drawings from a mental status examination)
need to be immediately copied and thrown out. The health psychology
consultant will notice that other providers will take similar precautions
(e.g., a dedicated stethoscope is left in the patient’s room for all providers
to use with only that patient; patients use plastic silverware, cardboard
trays, and paper dishes that can be thrown out rather than cleaned and used
again with another patient). The general rule is that any object that goes
into the room of a patient on transmission-based precautions does not
come back out to be used elsewhere.

Summary and Additional Suggestions

The hospital setting is unique, and psychologists who have not worked in
this setting will need to educate themselves so that they can function
responsibly and effectively in the hospital milieu. The American
Psychological Association (1985) has provided a list of suggestions for
psychologists who are working in a hospital setting, designed to help the
psychologist establish credibility and fit in. These are listed and expanded
upon in Exhibit 1.4. Colleagues and other hospital staff can also be good

32
resources who can answer questions on credentialing, documentation,
precautions, and other issues. As the health psychology consultant begins
to function in the hospital, he will develop his own professional style,
discussed more in Chapter 16.

EXHIBIT 1.4
Suggestions for Psychologists in the Hospital
Use plain English, not “psychologese”: Be aware that your notes and reports
are not being written for other mental health professionals, so avoid
psychological jargon and abbreviations (e.g., SI for suicidal ideation).
Be action-oriented. Medical providers in the hospital may ask what to do;
don’t hesitate to tell them (e.g., discuss the treatment plan with the patient
again; explain what needs to happen prior to discharge).
Be brief. Written and verbal reports need to be clear and to the point, or you
will lose your audience and not be perceived as helpful to them.
Know what you are doing, and know your limits. If you don’t know
something, admit it.
Doctors are generally quite willing to explain a medical issue. If there is a
question you can research to find the answer to, especially of a
psychological nature, do it and report back. Never say you will find
something out and then drop it without an answer.
Be polite, friendly, and helpful when it is appropriate. Be friendly to hospital
staff members, remember their names, demonstrate that you can be helpful
with the patient.
Do not feel like a second-class citizen. You have a right to be in the hospital,
and your work will demonstrate to your medical colleagues that you have
skills and resources that can be valuable to them and their patients.
Be flexible in how you practice. Be aware of different contexts on specialized
units of the hospital (e.g., preferences for immediate call backs on patients
versus reports at daily team meetings) and adjust your work appropriately.
Do not form inappropriate alliances on the treatment team. While a social
worker and psychologist might tend to see things similarly, do not collude to
push certain agendas.
At times it may be appropriate to offer support to a member of the treatment
team, but it is not your responsibility to care for their mental health needs or
to resolve conflicts between others.
Respect the hierarchy of the situation. Be aware of issues of rank and respond

33
 appropriately. Remember that you are treating the medical team’s patient.
You may also need to provide feedback to several members of the team
independently to ensure that everyone is on the same page.
Note. Adapted from A Hospital Practice Primer for Psychologists (pp. 29–30), by the Committee
on Professional Practice of the Board of Professional Affairs, 1985, Washington, DC: American
Psychological Association. Copyright 1985 by the American Psychological Association.

34
T he biopsychosocial model is the foundation on which all of health
psychology inpatient consultation is built. Initially proposed by Engel
(1977, 1980) in response to the limitations of the biomedical model, the
biopsychosocial model includes psychological and social aspects of the
human experience, which were not previously considered in the
conceptualization of medical illness. There is currently general agreement
that medical treatment is most successful when the conceptualization of a
patient’s illness includes biological, psychological, and social factors.
Using the biopsychosocial model, a holistic conceptualization of the
medical problem can be translated into a comprehensive treatment plan
that is informed by all relevant factors.
Medical treatment is less successful if the biological, psychological,
and social factors are not considered simultaneously. Consider Mr. S, who
is a patient with diabetes mellitus and end-stage renal disease. His doctor
recommends treatment with insulin and hemodialysis. However, Mr. S
does not understand the relationship between these proposed interventions
and his disease, so he has no motivation to deal with the inconvenience of
these treatments. He also has no social support to help him understand the
treatment plan, learn to self-administer insulin, and organize transportation
to dialysis. As a result, he does not adhere to the treatment

35
Another random document with
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among the trees
 This ebook is for the use of anyone anywhere in the United
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eBook.

Title: A year among the trees

or, the woods and by-ways of New England

Author: Wilson Flagg

Release date: January 9, 2024 [eBook #72670]

Language: English

Original publication: Boston: Educational Publishing Company,

1881

Credits: Richard Tonsing, Emmanuel Ackerman, Steve Mattern,

and the Online Distributed Proofreading Team at
https://www.pgdp.net (This file was produced from
images generously made available by The Internet
Archive)

*** START OF THE PROJECT GUTENBERG EBOOK A YEAR

AMONG THE TREES ***
Transcriber’s Note:
New original cover art included with this eBook is
granted to the public domain.
 A Year among the Trees;

OR,

THE WOODS AND BY-WAYS OF NEW

ENGLAND.

By WILSON FLAGG,
AUTHOR OF “STUDIES IN THE FIELD AND FOREST,” “A YEAR WITH THE
BIRDS,” “HALCYON DAYS,” ETC.

The temples of the gods made desolate,

They leave the earth to curses born of art;
Degenerate man resumes the bow and quiver,
And beauty sleeps until another dawn.

BOSTON:
EDUCATIONAL PUBLISHING CO.
1890.
 COPYRIGHT, 1881,
BY ESTES AND LAURIAT.
BOSTON.

COPYRIGHT, 1889,
BY EDUCATIONAL PUBLISHING CO.,
BOSTON.
INDEX.
 A.
Ailantus 267
Alder Alnus serrulata 265
American Elm 74
American Wayfaring-Tree Viburnum lentago 185
Andromeda 209
Animals of the Primitive Forest 12
Apple-Tree Pyrus malus 70
Arbor-Vitæ Thuya occidentalis 299
Arrow-Wood Viburnum dentatum 187
Ash Fraxinus Americana 8
Ash, Mountain 86
Aspen, large Populus tripida 257
Aspen, small Populus tremuloides 258
Autumn Woods 188
Azalea 18

B.
Balsam Fir Abies balsamea 288
Barberry Berberis communis 48
Bayberry Myrica cerifera 178
Beach-Plum Prunus maritima 72
Bearberry Arbutus uva-urs 143
Beech-Tree Fagus Americanus 145
Benzoin Laurus benzoin 135
Bittersweet Celastrus scandens 151
Blackberry Rubus procumbens 152
Black Birch Betula lenta 237
Black Poplar Populus nigra 247
Black Spruce Abies nigra 291
Black Walnut Juglans nigra 164
Buckthorn Rhamnus catharticus 270
Burning-Bushes 269
Butternut Juglans cinerea 163
Button-bush Cephalanthus occidentalis 172
Buttonwood 174
 C.
Canada Poplar Populus candicans 246
Canadian Rhodora 19
Catalpa 41
Ceanothus 49
Checkerberry Gaultheria procumbens 143
Cherry, Black Prunus Virginiana 81
Cherry, Choke Prunus serotina 82
Chestnut Castanea vesca 154
Chokeberry Mespilus arbutifolia 85
Clethra Clethra alnifolia 173
Clipped Hedge-rows 136
Cornel 200
Cornel, Blue-berried Cornus circinata 201
Cornel, Dwarf Cornus Canadensis 202
Cornel, Florida Cornus Florida 201
Cornel, Purple-berried Cornus alternifolia 200
Cornel, White-berried Cornus alba 200
Cypress, Northern Cupressus thuyoides 293
Cypress, Southern Taxodium distichum 294

D.
Dark Plains 223
Dewberry Rubus sempervirens 152
Dogwood Rhus vernix 204
Dutch Myrtle Myrica gale 178

E.
Eglantine Rosa micrantha 218
Elder Sambucus Canadensis 206
Elm, American Ulmus Americanus 74
Elm, English Ulmus campestris 80
Elm, White Ulmus Americanus 74

F.
Fir Picea 288
Flowering Dogwood 200
Flowering Raspberry Rubus odoratus 152
Foliage 51
Forms and Expressions of Trees 42

G.
Glycine Glycine apios 150
Grapevine Vitis labrusca 152
Ground Laurel Epigea repens 142
Guelder Rose Viburnum opulus 186

H.
Hardhack Spiræa tomentosa 114
Hawthorn Cratægus oxyacantha 115
Hazel, Beaked Corylus rostrata 172
Hazel, Common Corylus Americana 171
Heath Erica 208
Hemlock Abies Canadensis 279
Hickory 156
Hickory, Bitternut Carya amara 157
Hickory, Fignut Carya ficiformis 157
Hickory, Shellbark Carya squamosa 157
Hickory, White Carya alba 157
Hobblebush Viburnum lantanoides 186
Holly Ilex opaca 113
Honey Locust Gleditschia 108
Hop Hornbeam Ostrya Virginica 61
Hornbeam Carpinus Americana 60
Horse-Chestnut Æsculus 40

I.
Indian Summer 240
Insecurity of our Forests 63

J.
Jersey Tea Ceanothus Americana 49
Juniper Juniperus Virginiana 297
 K.
Kalmia 96

L.
Lambkill Kalmia angustifolia 98
Larch Larix Americana 277
Laurel Laurus 134
Laurel, Low 98
Laurel, Mountain 96
Lilac Syringa 47
Lime Tilia Americana 93
Linden-Tree 93
Locust Robinia pseudacacia 106
Lombardy Poplar Populus fastigiata 254

M.
Magnolia Magnolia glauca 105
Maple Acer 220
Meadow-Sweet Spiræa alba 114
Mespilus, Snowy 84
Missouri Currant Ribes aureum 49
Motions of Trees 100
Mountain Ash Sorbus Americana 86
Mountain Laurel Kalmia latifolia 96
Mountain Maple Acer montana 221
Myrtle Myrtus 177

N.
Northern Cypress Cupressus thuyoides 293
Norway Spruce Abies excelsa 291

O.
Oak 121
Oak, Black Quercus tinctoria 133
Oak, Red Quercus rubra 131
Oak, Scarlet Quercus coccinea 132
Oak, Scrub Quercus ilicifolia 132
Oak, Swamp Quercus bicolor 130
Oak, White Quercus alba 129
Orchard Trees 69

P.
Peach-Tree Amygdalus 73
Pear-Tree Pyrus 71
Pine, Pitch Pinus rigidus 305
Pine, White Pinus strobus 301
Pine Woods 282
Plane-Tree Platanus occidentalis 174
Plum-Tree Prunus 72
Plumgranate Prunus Americana 72
Poison Ivy Rhus radicans 150
Poplar Populus 245
Primitive Forest, The 1
Privet Ligustrum vulgare 270

Q.
Quince-Tree Pyrus cydonia 72

R.
Red Birch Betula rubra 239
Red Maple Acer rubrum 228
Red Osier Cornus circinata 201
Relations of Trees to the Atmosphere 109
Relations of Trees to Birds and Insects 233
Relations of Trees to Poetry and Fable 260
Relations of Trees to Salubrity 212
Relations of Trees to Soil 181
Relations of Trees to Temperature 159
Relations of Trees to Water 88
Rhodora Rhodora Canadensis 19
River Maple Acer 222
River Poplar Populus rivalis 248
Rock Maple Acer saccharinum 221
Rose Rosa 217
Rotation and Distribution 25
Rustic Lane and Woodside 148

S.
Sassafras Laurus sassafras 134
Snow-ball Tree 186
Snowy Mespilus Mespilus Canadensis 84
Sounds from Trees 249
Southern Cypress 294
Spindle-Tree Euonymus 269
Spiræa 114
Spruce Abies 290
Spruce, Black Abies nigra 291
Spruce, Norway Abies excelsa 291
Spruce, White Abies alba 290
Strawberry-Tree Euonymus 269
Sugar Maple Acer saccharinum 221
Sumach, Poison Rhus vernix 204
Sumach, Poison Ivy Rhus radicans 152
Sumach, Smooth Rhus glabrum 204
Sumach, Velvet Rhus typhinum 204
Summer Wood-scenery 117
Swamp Honeysuckle Azalea viscosa 18
Swamp Rose Rosa Caroliniana 218
Sweetbrier Rosa micrantha 218
Sweet-Fern Comptonia asplenifolia 179
Sweet-gale 178
Synopsis of Autumn Tints 197

T.
Trees as Electric Agents 137
Trees for Shade and Salubrity 212
Trees in Assemblages 125
Tulip-Tree Liriodendron tulipifera 104
Tupelo Nyssa villosa 58
 V.
Vernal Wood-scenery 35
Viburnum, Arrow-Wood V. dentatum 187
Viburnum, Hobblebush V. lantanoides 186
Viburnum, Maple-leaved V. acerifolium 186
Viburnum, Wayfaring-Tree V. lentago 185
Virginia Creeper Ampelopsis 149
Virgin’s Bower Clematis 153

W.
Weeping Willow Salix Babylonica 32
Western Plane Platanus occidentalis 174
White Birch Betula alba 230
White Pine Pinus strobus 301
White Spruce Abies alba 290
Whortleberry Pasture 165
Whortleberries and Huckleberries 170
Willow 21
Willow, Swamp Salix eriocephala 22
Willow, Yellow Salix vitellina 24
Winter Wood-scenery 271
Witch-Hazel 266
Woody Nightshade Solanum dulcamara 150

Y.
Yellow Birch Betula excelsa 238
Yew Taxus Canadensis 300
 PREFACE.

The matter contained in this volume is taken wholly from “The

Woods and By-Ways of New England,” omitting all that is published
in Volume I., and which has no special reference to trees. This
volume, beside the particular description of species, treats of the
value and beauty of trees and forests, of their climatic influence as
purifiers of the atmosphere, of their relations to water, to electricity,
to temperature, to the soil, to shade and salubrity, to birds and
insects, to ornament, and to poetry and fable.
THE WOODS.
 A YEAR AMONG THE TREES;

OR,

THE WOODS AND BY-WAYS OF NEW

ENGLAND.

THE PRIMITIVE FOREST.

When the Pilgrim first landed on the coast of America, the most
remarkable feature of its scenery that drew his attention, next to the
absence of towns and villages, was an almost universal forest. A few
openings were to be seen near the rivers,—immense peat-meadows
covered with wild bushes and gramineous plants, interspersed with
little wooded islets, and bordered on all sides by a rugged, silent, and
dreary desert of woods. Partial clearings had likewise been made by
the Indians for their rude hamlets, and some spaces had been
opened by fire. But the greater part of the country was darkened by
an umbrageous mass of trees and shrubbery, in whose gloomy
shades were ever present dangers and bewilderment for the traveller.
In these solitudes the axe of the woodman had never been heard, and
the forest for thousands of years had been subject only to the
spontaneous action of natural causes. To men who had been
accustomed to the open and cultivated plains of Europe, this waste of
woods, those hills without prospect, that pathless wilderness, and its
inhabitants as savage as the aspect of the country, must have seemed
equally sublime and terrible.
But when the colonists had cut roads through this desert, planted
landmarks over the country, built houses upon its clearings, opened
the hill-tops to a view of the surrounding prospect, and cheered the
solitude by some gleams of civilization, then came the naturalist and
the man of science to survey the aspect and productions of this new
world. And when they made their first excursions over its rugged
hills and through its wooded vales, we can easily imagine their
transports at the sight of its peculiar scenery. How must the early
botanist have exulted over this grand assemblage of plants, that bore
resemblance to those of Europe only as the wild Indian resembles the
fair-haired Saxon! Everywhere some rare herb put forth flowers at
his feet, and trees of magnificent height and slender proportions
intercepted his progress by their crowded numbers. The wood was so
generally uninterrupted, that it was difficult to find a summit from
which he could obtain a lookout of any considerable extent; but
occasional natural openings exposed floral scenes that must have
seemed like the work of enchantment. In the wet meadows were
deep beds of moss of the finest verdure, which had seldom been
disturbed by man or brute. On the uplands were vast fields of the
checkerberry plant, social, like the European heath, and loaded half
the year with its spicy scarlet fruit. Every valley presented some
unknown vegetation to his sight, and every tangled path led him into
a new scene of beauties and wonders. It must have seemed to him,
when traversing this strange wilderness, that he had entered upon a
new earth, in which nature had imitated, without repeating, the
productions of his native East.
Along the level parts of New England and the adjacent country,
wherever the rivers were languid in their course, and partially
inundated their banks in the spring, were frequent natural meadows,
not covered by trees,—the homes of the robin and the bobolink
before the white man had opened to them new fields for their
subsistence. In the borders of these openings, the woods in early
summer were filled with a sweet and novel minstrelsy, contrasting
delightfully with the silence of the deeper forest. The notes of the
birds were wild variations of those which were familiar to the Pilgrim
in his native land, and inspired him with delight amidst the all-
prevailing sadness of woods that presented on the one hand scenes
both grand and beautiful, and teemed on the other with horrors
which only the pioneer of the desert could describe.
The whole continent, at the time of its discovery, from the coast to
the Great American Desert, was one vast hunting-ground, where the
nomadic inhabitants obtained their subsistence from the chase of
countless herds of deer and buffalo. At this period the climate had
not been modified by the operations of man upon the forest. It was
less variable than now, and the temperature corresponded more
definitely with the degrees of latitude. The winter was a season of
more invariable cold, less interrupted by thaws. In New England and
the other Northern States, snow fell in the early part of December,
and lay on the ground until April, when the spring opened suddenly,
and was not followed by those vicissitudes that mark the season at
the present era. Such was the true forest climate. May-day came
garlanded with flowers, lighted with sunshine, and breathing the
odors of a true spring. It was then easy to foretell what the next
season would be from its character the preceding years. Autumn was
not then, as we have often seen it, extended into winter. The limits of
each season were more precisely defined. The continent was annually
visited by the Indian summer, that came, without fail, immediately
after the fall of the leaf and the first hard frosts of November. This
short season of mild and serene weather, the halcyon period of
autumn, has disappeared with the primitive forest.
The original circumstances of the country have been entirely
revolutionized. The American climate is now in that transition state
which has been caused by opening the space to the winds from all
quarters by operations which have not yet been carried to their
extreme limit. These changes of the surface have probably increased
the mean annual temperature of the whole country by permitting the
direct rays of the sun to act upon a wider area, while they have
multiplied those eccentricities of climate that balk our weather
calculations at all seasons. There are still in many parts of the
country large tracts of wood which have not been greatly disturbed.
From the observation of these, and from descriptions by different