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FIFTH EDITION
CASE FILES®
Obstetrics and
Gynecology
Eugene C. oy, MD Patti Jayne Ross, MD
Assistant Dean or Educational Programs Pro essor
Director o Doctoring Courses Program University o exas H ealth Science Center
Director o the Scholarly Concentrations Department o O bstetrics and Gynecology
in Women’s H ealth McGovern Medical School at T e University
Pro essor and Vice Chair o Medical Education o exas H ealth Science Center at H ouston
Department o O bstetrics and Gynecology (U H ealth)
McGovern Medical School at T e University H ouston, exas
o exas H ealth Science Center at H ouston
(U H ealth) John C. Jennings, MD
H ouston, exas Pro essor o O bstetrics and Gynecology
exas ech University H ealth Sciences Center
Benton Baker III, MD Odessa, exas
Fellow, American College o O bstetricians and
Gynecologists
Retired, Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University
o exas H ealth Science Center at H ouston
(U H ealth)
H ouston, exas
New York Chicago San Francisco Athens London Madrid Mexico City
Milan N ew Delhi Singapore Sydney oronto
Copyright © 2016 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States
Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or
stored in a database or retrieval system, without the prior written permission of the publisher.
ISBN: 978-0-07-184379-9
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Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in
treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed
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DEDICATION
T is f th edition o Case Files®: Obstetrics and Gynecology is dedicated to Dr. Sean

C. Blackwell, who is my chairman, and whose leadership and riendship I cherish.
I have watched him work tirelessly rom be ore dawn to well a ter dusk, and be
available or telephone calls and consultation regardless o the hour. H e is the rea-
son I am able to continue to grow as an educator, writer, and teacher. Most precious
to me, he strongly supported me (shortly a ter joining the department ull time) to
keep my commitment to lead our medical mission team to Cambodia to serve hun-
dreds in the rural province o Kratie. H e is probably the biggest reason this edition o
Case Files®: Obstetrics and Gynecology could see print.
Sean C. Blackwell, MD is a Pro essor and Chair (appointed 2011) o the Depart-
ment o O bstetrics, Gynecology and Reproductive Sciences at McGovern Medical
School at T e University o exas H ealth Science Center at H ouston (U H ealth).
Dr. Blackwell completed his undergraduate degree as a double major in the classics
and biology at Wabash College in Craw ordsville, Indiana. H e matriculated medi-
cal school at the University o Illinois College o Medicine in 1993 and completed
both his obstetrics and gynecology residency and maternal etal medicine ellowship
at Wayne State University in Detroit, Michigan. H e joined U H ealth in 2007,
and also serves as the Director o the Larry C. Gilstrap MD Center or Perinatal
and Women’s H ealth Research and as an Assistant Dean or H ealthcare Quality
in Perinatal Medicine and Women’s H ealth. Dr. Blackwell is the Chie o Service
or O bstetrics and Gynecology or Children’s Memorial H ermann H ospital– exas
Medical Center. In 2014, Dr. Blackwell earned his Six Sigma-Lean Black Belt at the
University o H ouston.
Eugene C. oy, MD
iv DEDICATION
o my Chairman o Obstetrics o Gynecology, Dr. Sean Blackwell,

whose work ethic, leadership, and vision inspire everyone around him
to excellence and whose heart o generosity touches thousands o
pregnant women and their babies.
—ECT
With love and gratitude, to Mom, Joy, Ben, Anne, Jessica, Jim, John,
and Col. Alvin Sholk.
—BB III
o Dr. James Knight, and ulane Medical School, or giving me the
opportunity to ulf ll my dreams. o my parents, Mary and Jimmy Ross,
or their love, inspiration, and devotion.
—PJR
o my wi e, Sue Ellen, my three daughters, Beth, Allison, and Amy,
their husbands, and my f ve grandchildren.
—JCJ
Finally, to the wonder ul medical students rom the McGovern Medical School
at T e University o exas Health Science Center at Houston (U Health),
who graciously gave constructive eedback
and enthusiastically received this curriculum.
—TH E AUTH ORS
CONTENTS
Contributors / vii
Pre ace / xiii
Acknowledgments / xv
Introduction / xvii
Listing o Cases / xix
Section I
How to Approach Clinical Problems ...................................................................1
Part 1. Approach to the Patient ................................................................................................. 3
Part 2. Approach to Clinical Problem Solving ....................................................................11
Part 3. Approach to Reading ....................................................................................................13
Part 4. Approach to Surgery .....................................................................................................18
Section II
Cases...................................................................................................................19
Obstetric Topics (Cases 1-28)...............................................................................................19
Gynecologic Topics (Cases 29-60)................................................................................... 289
Section III
Review Questions ...................................................................................................................... 565
Index / 577
This page intentionally left blank
CONTRIBUTORS
Mazen Elias Abdallah, MD

Assistant Pro essor o O bstetrics and Gynecology
McGovern Medical School at T e University o exas
H ealth Science Center at H ouston (U H ealth)
H ouston, exas
Delayed Puberty
Michael . Adler, MD
H ouston, exas
Amenorrhea, Intrauterine Adhesions
Elizabeth E. Brackett
Medical Student
H ouston, exas
Herpes Simplex Virus In ection in Pregnancy
Shao-Chun R. Chang-Jackson, MD
H ouston, exas
Ectopic Pregnancy
amika K. Cross, MD
Resident in O bstetrics and Gynecology
H ouston, exas
Domestic Abuse and Sexual Abuse
Cynthia Donna, MD
H ouston, exas
Contraception
Erin G. Dressel
Medical Student
H ouston, exas
Hypertensive Disease in Pregnancy
vii
viii CONTRIBUTORS
Amy E. Dudley
Medical Student
H ouston, exas
Bacterial Vaginosis
Jenny Duret-Uzodinma, MD
H ouston, exas
Pyelonephritis in Pregnancy
Russell Edwards, MD, FACOG
Faculty, O bstetrics and Gynecology Residency Program
T e Methodist H ospital—H ouston
H ouston, exas
Galactorrhea and Hypothyroidism
Konrad Harms, MD, FACOG
Assistant Clinical Pro essor o O bstetrics and Gynecology
Weill Cornell Medical College
Program Director,
O bstetrics and Gynecology Residency
H ouston, exas
Shoulder Dystocia
Sara B. Holcombe, DO
H ouston, exas
Domestic Abuse and Sexual Assault
Steven Blaine Holloway
Medical Student
H ouston, exas
Cystitis
Katlyn Hoover
Medical Student
H ouston, exas
Placental Abruption
CONTRIBUTORS ix
Lina Wael Irshaid

Medical Student
Weill Cornell Medical - Qatar
Dohn, Qatar
Intrauterine Growth Restriction
Randa J. Jalloul, MD, FACOG
H ouston, exas
Breast Cancer
Erin Josserand
Medical Student
H ouston, exas
Pulmonary Embolism in Pregnancy
Joy Y. Kim, MD
H ouston, exas
Contraception
Patricia C. Lenihan
Medical Student
H ouston, exas
Approach to Labor
Hypertension in Pregnancy
Pelvic Organ Prolapse
Principal manuscript reviewer
Chunhua Lu, MD, PhD
H ouston, exas
Breast Cancer
Fangxian Lu, MD, PhD
H ouston, exas
Postpartum Hemorrhage
x CONTRIBUTORS
Michael S. MacKelvie, DO
H ouston, exas
Placenta Accreta
Violet Maldonado
Medical Student
H ouston, exas
Preterm Labor
Dalia M. Moghazy, MD
H ouston, exas
Intrahepatic Cholestasis o Pregnancy
Alyxandra O’Brien, MD
H ouston, exas
Ectopic Pregnancy
Christine Pan, MD
H ouston, exas
Postpartum Hemorrhage
Urinary Incontinence
Virginia A. Rauth, MD, MBA
Pro essor o O bstetrics and Gynecology
Chie o Women’s H ealthCare at Galveston
University o exas Medical Branch
Galveston, exas
Approach to Perimenopause
John W. Riggs, MD, MS, FACOG
Pro essor o O bstetrics and Gynecology
H ouston, exas
Postpartum Endometritis
CONTRIBUTORS xi
Reem Sabouni, MD
H ouston, exas
Amenorrhea, Intrauterine Adhesions
Placenta Previa
Mary Alice Sallman
Medical Student
Manuscript reviewer
Viviana C. Salom-Ellis
Medical Student
H ouston, exas
Placenta Previa
Priti P. Schachel, MD, FACOG
Associate Program Director
O bstetrics and Gynecology Residency Program
H ouston, exas
Intrahepatic Cholestasis o Pregnancy
Nicholas R. Spencer
Medical Student
H ouston, exas
Parvovirus In ection in Pregnancy
Lauren Jane T arp, MD
Administrative Chie Resident in O bstetrics and Gynecology
H ouston, exas
Postpartum Endometritis
Aida L. Vigil, MD, MPH
H ouston, exas
Pyelonephritis in Pregnancy
xii CONTRIBUTORS
Joaquin Andres Villegas Inurrigarro

Medical Student
H ouston, exas
Septic Abortion
Cristina M. Wallace, MD
H ouston, exas
Polycystic Ovarian Syndrome
Amberly Nesbitt Winley, MD
H ouston, exas
Polycystic Ovarian Syndrome
Nikolaos Zacharias, MD, FACOG
H ouston, exas
Placenta Accreta
PREFACE
I have been deeply amazed and grate ul to see how the Case Files®books have been
so well received, and have helped students to learn more e ectively. In the 13 short
years since Case Files®: Obstetrics and Gynecology irst made it in print, the series
has now multiplied to span most o the clinical and basic science disciplines, and
been translated into nearly 20 oreign languages. Numerous students have sent
encouraging remarks about the changes in the ourth edition, which divided up
into O bstetrics in the irst hal , and Gynecology in the second hal to be more “user-
riendly” during the clerkship since most students have their rotation divided in
those two categories. In this i th edition, we have retained the grouping o related
cases closer together to allow students to use in ormation rom one case to rein-
orce principles to another case, and cross-re erenced-related cases. Although space
is always a premium, we have also retained and expanded Section III which is a col-
lection o strategic questions that can be used or review, but also to tie in the prin-
ciples rom the cases. Questions have been improved to better re lect the USMLE
ormat, and explanations have been expanded to help the student understand the
mechanisms and the reason that the other choices are incorrect. wo completely
new cases (Sexual Abuse/ Intimate Partner Violence, and Chronic Pelvic Pain) have
been written. Updated or new sections include cervical cytology screening, con-
traception, labor management, hypertension in pregnancy, etal assessment, and
ovarian cancer. his i th edition has been a collaborative work with my wonder-
ul coauthors and contributors, and with the suggestions rom ive generations o
students. ruly, the enthusiastic encouragement rom students throughout not just
the United States but worldwide provides me with the inspiration and energy to
continue to write. It is thus with humility that I o er my sincere thanks to students
everywhere … or without students, how can a teacher teach?
Eugene C. oy
xiii
ACKNOWLEDGMENTS
he curriculum that evolved into the ideas or this series was inspired by two talented
and orthright students, Philbert Yao and Chuck Rosipal, who have since graduated
rom medical school. It has been a tremendous joy to work with my riend, colleague,
and my ob/ gyn program director, Dr. Bentor Baker III. It is also a privilege to work
with Dr. Ross, who has been a steady hand in administrating the medical student
clerkship or so many years. It is a personal honor and with extreme gratitude that I
am able to work with Dr. John Jennings, a visionary, brilliant obstetrician gynecolo-
gist, leader, and riend. Also, I am awed by the many excellent contributors who con-
tinue to work under the deadlines and pleas o per ectionists. I am greatly indebted
to my editor, Catherine Johnson, whose exuberance, experience, and vision helped
to shape this series. I appreciate McGraw-H ill’s believing in the concept o teach-
ing through clinical cases. I am also grate ul to Catherine Saggese or her excellent
production expertise, and Cindy Yoo or her wonder ul editing. At the University o
exas Medical School at H ouston, I appreciate the support rom my chairman
Dr. Sean Blackwell, who is an amazing leader with a brilliant intellect, an unparalleled
work ethic, and a generous heart that inspires beyond our department; and Dr. Patricia
Butler who as Vice Chair or Educational Programs o our school exempli ies all
that is excellent in medical education, and has served as a role model and mentor
or me. I appreciate Yaki Bryant, who has aith ully and energetically served as the
extraordinary student coordinator or literally thousands and thousands o students
at the University o exas Medical School at H ouston. I want to acknowledge the
many medical students who have helped to sharpen the ocus o this book, especially
Patricia Lenihan, who served as principle manuscript reviewer. Most o all, I appre-
ciate my loving wi e, erri, and my our wonder ul children, Andy and his wi e Anna,
Michael, Allison, and Christina, or their patience and understanding.
Eugene C. oy
xv
INTRODUCTION
Mastering the cognitive knowledge within a ield such as obstetrics and gynecology
is a ormidable task. It is even more di icult to draw on that knowledge, to procure
and ilter through the clinical and laboratory data, to develop a di erential diagnosis,
and inally to make a rational treatment plan. o gain these skills, the student o ten
learns best at the bedside, guided and instructed by experienced teachers, and
inspired toward sel -directed, diligent reading. Clearly, there is no replacement or
education at the bedside. Un ortunately, clinical situations usually do not encom-
pass the breadth o the specialty. Perhaps the best alternative is a care ully cra ted
patient case designed to stimulate the clinical approach and decision making. In an
attempt to achieve that goal, we have constructed a collection o clinical vignettes
to teach diagnostic or therapeutic approaches relevant to obstetrics and gynecology.
Most importantly, the explanations or the cases emphasize the mechanisms and
underlying principles, rather than merely rote questions and answers.
his book is organized or versatility: It allows the student “in a rush” to go
quickly through the scenarios and check the corresponding answers, and it pro-
vides more detailed in ormation or the student who wants thought-provoking
explanations. he answers are arranged rom simple to complex: a summary o
the pertinent points, the bare answers, an analysis o the case, an approach to the
topic, a comprehension test at the end or rein orcement and emphasis, and a list o
resources or urther reading. he clinical vignettes have been arranged as O bstetri-
cal in the irst hal , and Gynecology in the second hal , and related cases grouped
together. Section III contains Review Questions designed to require higher level
integration o in ormation. A listing o cases is included in Section IV to aid the
students who desire to test their knowledge o a speci ic area, or who want to
review a topic including basic de initions. Finally, we intentionally did not use a
multiple-choice question (MCQ) ormat in our clinical case scenarios, since clues
(or distractions) are not available in the real world. N evertheless, several MCQs are
included at the end o each case discussion (Comprehension Questions) to rein-
orce concepts or introduce related topics.
HOW TO GET THE MOST OUT OF THIS BOOK

Each case is designed to simulate a patient encounter with open-ended questions.
At times, the patient’s complaint is di erent rom the most concerning issue, and
sometimes extraneous in ormation is given. he answers are organized into our
di erent parts:
CLINICAL CASE FORMAT: PART I

1. Summary: he salient aspects o the case are identi ied, iltering out the extra-
neous in ormation. Students should ormulate their summary rom the case
be ore looking at the answers. A comparison to the summation in the answer will
help to improve their ability to ocus on the important data, while appropriately
xvii
xviii INTRODUCTION
discarding the irrelevant in ormation—a undamental skill in clinical problem

solving.
2. A Straightforward Answer is given to each open-ended question.
3. he Analysis of the Case is comprised o two parts:
a. O bjectives of the Case: A listing o the two or three main principles that
are crucial or a practitioner to manage the patient. Again, the students are
challenged to make educated “guesses” about the objectives o the case upon
initial review o the case scenario, which helps to sharpen their clinical and
analytical skills.
b. Considerations: A discussion o the relevant points and brie approach to
the speci ic patient.
PART II
Approach to the Disease Process: It consists o two distinct parts:
a. Definitions: erminology pertinent to the disease process.
b. Clinical Approach: A discussion o the approach to the clinical problem in
general, including tables, igures, and algorithms.
PART III
Comprehension Q uestions: Each case contains several multiple-choice questions,
which rein orce the material, or which introduce new and related concepts.
Q uestions about material not ound in the text will have explanations in the
answers.
PART IV
Clinical Pearls: Several clinically important points are reiterated as a summation of the
text. This allows for easy review, such as before an examination.
LISTING OF CASES
LISTING BY CASE NUMBER

CASE NO. DISEASE CASE PAGE
1 Labor (Latent Phase) 22

2 Anemia in Pregnancy ( halassemia rait) 42
3 Uterine Inversion 52
4 Shoulder Dystocia 60
5 Fetal Bradycardia (Cord Prolapse) 68
6 Postpartum H emorrhage 76
7 Serum Screening in Pregnancy 86
8 win Gestation with Vasa Previa 96
9 H erpes Simplex Virus In ection in Labor 104
10 Placenta Previa 112
11 Placental Abruption 120
12 Placenta Accreta 128
13 Abdominal Pain in Pregnancy (Ovarian orsion) 136
14 Pruritus (Cholestasis) o Pregnancy 146
15 Pulmonary Embolus in Pregnancy 154
16 Preeclampsia with Severe Features 166
17 Preterm Labor 180
18 Preterm Premature Rupture o Membranes (PPROM)
and Intra-Amniotic In ection 190
19 Parvovirus In ection in Pregnancy 198
20 Chlamydial Cervicitis and H IV in Pregnancy 208
21 hyroid Storm in Pregnancy 218
22 Intrauterine Growth Restriction 226
23 Pyelonephritis, Unresponsive 236
24 N ecrotizing Fasciitis 244
25 Postpartum Endomyometritis 250
26 Breast Abscess and Mastitis 256
27 Diabetes in Pregnancy 264
28 Prenatal Care 278
29 H ealth Maintenance, Age 66 Years 290
30 Perimenopause 298
31 Sexual Assault 306
32 Ureteral Injury a ter H ysterectomy 318
33 Pelvic Organ Prolapse 326
34 Fascial Disruption 334
xix
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Shake the swarm in as described at page 28, just as with a common
cottage hive.
If the weather be favourable, these two boxes will be nearly filled
in ten days. To get the full advantage of the Stewarton hive the first
year, put two swarms into two body boxes, a and b; if the two are too
small, then add the other box c. Allow the bees to remain there till
they have nearly filled the body boxes with comb, which (with this
increased number of workers, and in favourable weather) should be
from five to ten days. Two swarms are seldom procurable the same
day, so as then to be joined together, and even if they were, there is
a doubt whether greater progress may not be attained by hiving a
swarm a week or so earlier than the other, so as to build comb and
raise brood ready for the reception of the new comers.
The second swarm is added best in the evening, after the bees
have ceased working. For this purpose spread a sheet on the
ground, place two sticks so as to prevent the box being close to the
ground, then, with a sudden knock, eject the bees of the second
swarm on to the cloth, and place the two body boxes that contain the
earlier swarm over the dislodged bees; these will, in the course of an
hour or so, ascend and become one family, and one of the queens
will be speedily destroyed.
In the meantime, prepare the shallow honey-box d, by fixing
small pieces of worker guide-comb, of pure white colour, on the
centre of each side bar. If, however, a box of honey with neatly
made, straight, and quite regular comb be desired, a piece of this
guide-comb must be fixed to the centre of each bar. If guide-comb be
unobtainable, strips of the impressed wax sheets or artificial comb
(hereafter described) will be found excellent substitutes.[12]
[12] The body boxes may be prepared in a similar manner.
When selecting guide-comb, avoid combs with drone-cells; to fix

these is setting the bees a bad pattern. Honey stored in drone-
combs has more wax, and is coarser in appearance and taste.
Having satisfied yourself, by peeping in at the windows, and from
symptoms at the entrance, that the original boxes are well filled,
place your prepared honey-box on the top, draw a slide at each side
of the middle box to afford communication, and insert the little plugs.
It is not so well to withdraw the middle slides, because the queen is
more likely to ascend from the centre. When you notice that the bees
have fairly commenced work in the honey-box and are likely to keep
to it, the remaining box c may be added below the stock, which will
afford additional room and prevent swarming, exchanging the
entrance to the newly-furnished box and sliding in pieces wood to
close the aperture of that above.
Should the bees begin making comb in the bottom box, draw two
more slides for freer access into the super, as there will then be little
risk of the queen ascending, having so much range for egg-laying in
the three lower boxes.
In very fine weather, a good swarm or stock will fill a honey-box in
the space of two weeks; but a much longer time is usually occupied.
The more quickly the box is filled, the purer will be the colour of
the comb and honey, because bees very much discolour their work
when they have it long on hand. Before taking off the honey-box,
observe particularly that the combs are well sealed at the windows,
because, as mentioned at page 83, this portion of the work is always
left till the last.
When you see that all is ready for the removal of a box, select the
middle of a fine day for the purpose (not omitting to don the bee-
armour). Draw out one or two of the slides, and give the bees a few
gentle puffs, either of fungus or of tobacco smoke, from the tube
fumigator, which will cause the majority of the bees to descend into
the body of the hive; then stop the communication, by pushing in the
slides. Next, with a spatula, make a slight opening for a piece of
strong thin twine at the front of the box, and immediately behind the
thread two thin wedges; with the two ends in hand, work the twine
gently forward, bringing the wedges, after, until the opposite side is
reached. This will remove any obstruction caused by the bees
having attached their combs to the top of the next box, and thus
leave the super entirely free for removal. It will be as well, for the
reasons stated at page 58, not to remove the box immediately. After
waiting an hour, the box may be taken off, and conveyed to a quiet
place. Should any bees remain, they will be glad, after their
confinement, to escape to the parent hive; or if you have an empty
hive to put over, by gently drumming the sides, the remaining bees
will ascend and leave the box at your disposal. The bees driven into
the empty box may now be shaken out in front of the mouth of the
hive. Another plan is to cut off the communication over night, and
raise the hive on wedges, as recommended to be adopted with the
super (page 73).
Before winter sets in, the box c may be removed and the comb it
contains (if well filled) be used for consumption: if the comb be
empty, let it remain carefully preserved from moth and insects; it will
be invaluable next season. Empty comb may be thus preserved by
tying or pasting a piece of stout newspaper closely round the bottom,
and keeping the box in a dry place.
Feeding, when required, may be liberally pursued, by
withdrawing two slides and supplying a bottle-feeder. Enough food
should be given in the early autumn to last until spring.
The chief value of the Stewarton hive consists in the boxes being
shallow, so that the combs are more likely to be well filled down to
the base. This is a great advantage with supers, particularly when
required to be sent to a distance, as there is less likelihood of the
combs breaking down. A fine super of honey, that would be valuable,
is materially depreciated when it reaches its destination in a
damaged state, with the honey running from the cells. For the same
reason, when the weather is hot and the rays of the sun fall on the
hive, the combs might part from their foundations if there were no
intermediate bars, which is now the case in the stock-hive,
composed as it is of two boxes. If these two boxes were in one, the
depth of each comb would be twelve inches; and when filled with
brood and honey, would probably weigh 10 lbs. This is a great
weight to be supported in hot summer weather, when the wax is
softened by the heat. Another distinguishing feature that the
Stewarton hive possesses is the use of the box c, which, by giving
increased room, as the season advances, prevents what is often an
annoyance to the apiarian, viz., a late swarm—too late to be of any
value, and impoverishing the stock by a division of its numbers,
thereby perhaps impeding the completion of the super. A further
advantage of the box c, is that it induces the bees (who frequently
hang in dusters about the entrance) to carry on their labours instead
of remaining in enforced idleness.
We often receive from Scotland magnificent boxes of honey; the
fine quality is no doubt to be attributed to good pasturage, and to the
fact of keeping the stocks strong (see page 19), by adopting the
means before hinted at; and thus having hives well stored and well
populated early in the season, so that they may betimes take full
advantage of supplies of nectar in the flowers. Early honey is
generally the best in colour.
The old proverb runs:—"It is the early bird that finds the worm."
The hive that is strong is certain to produce the most honey. To make
this plain, we will suppose that a bee-keeper has a weakly hive; it will
take some weeks, if not months, to grow populous; and as soon as
the strength of the hive has recovered, the honey season will have
advanced, if not ended, whilst the strong stocks have been able to
take full advantage of the supplies, having an abundance of
labourers to collect the honey and store it in supers for their master.
To induce the bees to build quickly, cover up the super with as much
warm woollen covering as you can, as recommended for glasses,
page 65.
In fine seasons, and under good management, extra supers and
body boxes (the latter to be used as "nadirs") maybe required to
place above and below the supers and nadirs partly filled, in order to
reap the full benefit of the honey season; for with strong colonies one
box after another may be inserted, till the whole towers from six to
ten boxes high. This plan is, indeed, collecting honey while the sun
shines, but requires a greater amount of apiarian skill and good
pasturage to carry on in its entirety than is generally possessed. In
other words, we in the south may find it difficult to rival our
accomplished brother-apiarians north of the Tweed, for they do
wonders with the Stewarton hive.
HUBER'S HIVE.
To Francis Huber—not improperly styled the "Prince of
Apiarians"—we are indebted for more extensive and accurate
observations on the habits of the bee than have been contributed by
all other observers since the time of Aristotle.
During the early period of Huber's investigations, he prosecuted
them by means of single-comb hives, which allow of each side of the
comb being examined. He found, however, that there was one
important defect. The bees could not in these hives cluster together,
which is their natural method of withstanding the effects of a reduced
temperature. Huber hit upon the ingenious expedient of combining a
number of single-comb frames, so as to form one complete hive,
which could be opened, in order to expose any particular comb,
without disturbing the rest. From the manner of the opening and
closing of this hive, it has generally been called the "Leaf or Book
Hive." The division separating each comb is joined both back and
front with "butt hinges," fastened with a movable pin, on withdrawing
which, at either side, each comb and the bees on it may be
inspected as easily as if in a single-comb hive. Huber's leaf hive is
thus in appearance, as if several ordinary "History of England"
backgammon chess-boards were set up on end together. The floor-
board on which the hive stands is larger than the hive when closed,
so as to allow of its being opened freely at any particular "volume."
An entrance-way for the bees is hollowed-out of the floor-board as in
other hives. There is a glass window in each end of the hive, which
is provided with a shutter.
There is, however, one serious objection to Huber's hive, which,
though not noticed by him or his careful assistant, has prevented its
general use—that is, the difficulty there is in closing it without
crushing some of the bees—a catastrophe which, by exasperating
their comrades, is certain to interfere with any experiments. There is
no such risk in the bar and frame hive, whilst in it every facility
possessed by Huber's is retained; so that we strongly recommend
scientific apiarians to use some kind of bar and frame hive in
preference to Huber's. We have here introduced a description of
Huber's leaf hive (and should be glad to exhibit one) for the sake of
its historic interest, in connection with apiarian science. The
invention was invaluable for Huber himself, and it suggested to other
apiarians the adoption of the present plan of vertical bars and
frames.
The character of Huber and the circumstances under which he
pursued his observations are so remarkable, that we need scarcely
apologize for stating a few particulars respecting him here. He was
born at Geneva, in July, 1750, his family being in honourable station
and noted for talent. Just as he attained to manhood he lost his
sight, and remained blind to the end of his days. This apparently
insuperable obstacle in the way of scientific observation was
overcome by the remarkable fidelity with which Burnens, his
assistant, watched the bees and reported their movements to Huber.
Madame Huber also, who, betrothed to him before his calamity, had
remained constant in her affection, assisted in the investigations with
great assiduity during their long and happy wedded life. We quote
the following from "Memoirs of Huber," by Professor de Candolle:—
"We have seen the blind shine as poets, and distinguish
themselves as philosophers, musicians, and calculators; but it was
reserved for Huber to give a lustre to his class in the sciences of
observation, and on objects so minute that the most clear-sighted
observer can scarcely perceive them. The reading of the works of
Reaumur and Bonnet, and the conversation of the latter, directed his
curiosity to the history of the bees. His habitual residence in the
country inspired him with the desire, first of verifying some facts,
then of filling some blanks in their history; but this kind of observation
required not only the use of such an instrument as the optician must
furnish, but an intelligent assistant, who alone could adjust it to its
use. He had then a servant named Francis Burnens, remarkable for
his sagacity and for the devotion he bore his master. Huber practised
him in the art of observation, directed him to his researches by
questions adroitly combined, and, aided by the recollections of his
youth and by the testimonies of his wife and friends, he rectified the
assertions of his assistant, and became enabled to form in his own
mind a true and perfect image of the manifest facts. 'I am much more
certain,' said he, smiling, to a scientific friend, 'of what I state than
you are, for you publish what your own eyes only have seen, while I
take the mean among many witnesses.' This is, doubtless, very
plausible reasoning, but very few persons will by it be rendered
distrustful of their own eyesight."
The results of Huber's observations were published in 1792, in
the form of letters to Ch. Bonnet, under the title of "Nouvelles
Observations sur les Abeilles." This work made a strong impression
upon many naturalists, not only because of the novelty of the facts
stated and the excellent inductive reasoning employed, but also on
account of the rigorous accuracy of the observations recorded, when
it was considered with what an extraordinary difficulty the author had
to struggle.
Huber retained the clear faculties of his observant mind until his
death, which took place on the 22nd of December, 1831. Most of the
facts relating to the impregnation of the queen, the formation of cells,
and the whole economy of the bee-community, as discovered and
described by Huber, have received full confirmation from the
investigations of succeeding naturalists.
IV.—EXTERIOR ARRANGEMENTS
AND APPARATUS.
BEE-HOUSE TO CONTAIN TWO HIVES.
HERE is no contrivance for protecting' hives from the weather
so complete as a bee-house: one which also admits of an easy
inspection of the hives ranged therein is especially convenient
for lady bee-keepers.
Front View of Bee House.
The folding; doors behind the bee-house have only to be opened,

and the hives are at once exposed to full view; then, by raising the
upper hive or cover, the glasses may be deliberately inspected
without molestation from the bees, and the progress made by the
busy multitude in building and filling their combs may be watched by
the bee-keeper, from day to day, with great and increasing interest.
Under the roof on each side are openings to act as ventilators, to
allow the heated air to escape. With the sun shining on the house
and no escape of this kind, the heat would be retained inside, and
the temperature become that of an oven.
Here our engraving shows the back view of the bee-house, the
interior being furnished with two of our improved cottage hives. Two
suspended weights will be noticed; these are to balance the top
hives which cover the glasses; the cord for each runs on pulleys, so
that the covers can be easily raised and as easily shut down again
when the inspection is finished. We may here remark, that it is not
well to keep the glasses long exposed to full light and view.
The front of the bee-house being closely boarded, a passage-
way is contrived for the bees, by which they have egress and
ingress, without being able to gain access to the house. The hives
must be kept close to the front boarding of the house, to prevent the
opening of any crevices which the bees might mistake for the
entrance to their hives, and so find their way into the house. The
front view of this bee-house shows the ordinary contrivance for
entrance; the sliding zinc entrances may also be advantageously
fixed, as shown in the engraving of a bee-house to contain twelve
hives. In many parts of the country, hives and honey are sometimes
stolen from the garden; the bee-houses we furnish have a lock and
key to prevent depredations of this kind.
Care must be taken to keep the bee-houses free from spiders
and other insects. In some districts, ants are numerous and
troublesome. The plan we recommend for excluding them is to put
some pitch round the four supports of the bee-house, or, better still,
strips of loose flannel, or other woollen material that is absorbent,
which have previously been soaked in lamp oil. We use sperm oil, as
being the slowest-drying oil we know of. A piece of string will keep
the flannel close to the wood and then neither ant nor other insect
will pass up; so that Dy this simple means the hives may, so to
speak, be insulated, and placed beyond their reach. As the oil dries
up, it can easily be renewed. We have found this an effectual
remedy against these insidious enemies of bees.
BEE-HOUSE TO CONTAIN TWELVE HIVES

Back view of Bee-house, showing the Interior.
Where economy of room is a consideration, we fit up bee-houses
with a double row of hives, one above the other. Our engravings
show the back and front of a house of this kind, having an
ornamental zinc gutter to prevent the wet from dripping on to the
alighting-board.
When a number of hives are thus together, we colour the
alighting-boards differently, so that the bees may have a distinctive
mark by which each may know its own home, and not wander into its
neighbour's house. Bees readily enough receive a honey-laden
labourer into a hive; but if the wanderer be poor and empty, he will
be promptly repulsed, and may have to forfeit his life for his mistake.
Queens returning from their wedding trip are liable to mistake their
hive if all the entrances are so much alike that a noticeable
difference is not easily apparent. A queen entering a hive already
supplied with a fruitful sovereign would be certain to be killed. The
loss to the hive to which the queen belonged is a serious one. Hives
are often made queenless from this cause, and thereby reduced to
utter ruin, the bee-master perhaps attributing his failure to something
altogether different.
BEE-HOUSE TO CONTAIN NINE HIVES.

This engraving represents a bee-house adapted for having a
number of hives in a limited space,—three rows of hives, one above
the other.
We do not recommend a bee-house of this construction; it is
difficult to erect one to afford space for super hives, without its being
so inconveniently high as to be liable to be blown over by strong
winds.
Hives thus located in a bee-house are not exposed to so much
change of temperature, and the stocks generally pass the winter
well.
Here we may introduce the meditations of a German apiarian,
who describes the advantages of a bee-house for the bees, and his
own pleasure in watching over his pets in the winter, as they dwell so
comfortably and safely. It is true that Herr Braun associates still
choicer delights with the simple pleasures of bee-keeping, but as Mr.
Woodbury has not excluded the higher theme from his translation,
we need not hesitate to quote the whole:—
EVENING THOUGHTS IN JANUARY.
(Translated from the German by Adalbert Braun.)
BY A DEVONSHIRE BEE-KEEPER.
Within my little garden
Stands also a bee-house,
And bees therein protected
From sly tomtit or mouse.
How quietly they're sitting!

And little trouble give,
Beyond the needful watching
That undisturbed they live—
That all, indeed, are living

In strong, unbroken health,
And, in the brood-nest hanging,
Consume their hoarded wealth—
That in the dwindling store-room

Sufficient stores remain,
Until the rape-plant donneth
Its blossom-dress again!
Thus daily do I visit

My garden and my bees,
Neglecting thereby often
My dinner and my ease.
Thank God! they all were humming

Within their hives to-day;
Nor could I find a symptom
Of hunger or decay.
And yet what ardent longing

I feel, O Spring, for thee!
My darlings' gleesome frolics
Are happiness to me!
How would this anxious longing

Consume my very breast,
But for a little being
So full of love and jest.
In heat or cold that prattles

Around me ev'ry day,
And still, the throes of longing
By commune blithe and gay.
Ye bee-keepers can value

A joy that is complete;
It is my wife—the darling
Whose lips are honey-sweet.
With e'en the richest bee-stand

Were joy and pleasure gone,
If my heart's queen were wanting
And I left here alone.
Thus, her I love and honour,

No difference have we,
But ofttimes go together
Our little pets to see.
Her kisses sweet removing

All sorrow from my breast,
And honied joys surrounding
Proclaim us highly blest.
Mount Radford, Exeter. T. W. Woodbury.
ORNAMENTAL ZINC COVER.

The annexed engraving of the Ornamental Zinc Cover renders
but little description necessary. The illustration shows one of our
improved cottage hives on a stand. Three clumps of wood must be
driven into the ground, and the three iron rods supporting the
covering made fast to them with screws; there are screw holes in the
feet of the iron rods for the purpose. When thus secured, but little
fear need be entertained of its being blown over by high winds.
In the roof two pulleys are fixed, so that, by attaching a cord, the
upper hive covering the bell-glass supers may be raised with facility
for the purpose of observing the progress made by the bees.
The ornamental zinc cover will form a pleasing object in the
flower-garden, when placed in a suitable position on the grass plot. It
is painted green; the iron rods are of such a length as to support the
roof at a convenient height from the ground.
ZINC COVER.
This is a simple and inexpensive covering for any cottage straw

hive when exposed in the garden. It fits close on to the upper hive,
coming sufficiently low to protect it from sun and rain, without
obscuring the whole hive.
These covers are painted green—a colour that is generally
preferred.
TAYLOR'S ZINC COVER.
This zinc cover, introduced by H. Taylor, Esq., for his cottage

hive, will also be found useful as a protection from wet, for many
other descriptions of round straw hives.
BELL GLASSES.
To contain 10 lbs., 10 inches high, 7 inches wide.
To contain 6 lbs., 7 inches high, 5½ inches wide.
To contain 3 lbs., 5 inches high, 4 inches wide.
These bell glasses are used in the hives before described. The
largest is for Nutt's hive; the middle-sized is for our improved cottage
hive; the smallest glass is so very small that it is not often used, and
we do not recommend it. Bees will generally fill a middle-sized glass
quite as soon as one so small as this.
TAYLOR'S BELL GLASSES.
These glasses have been introduced by Mr. Taylor, and are

recommended as preferable to deep narrow glasses. The drawings
will show that they are straight at the sides, flat at the top inside, with
a knob outside to take hold by, through which is a half-inch opening
to admit a ventilating tube. The larger is six inches deep, twelve
inches wide; smaller, five inches deep, nine and a half inches wide.
The late Mr. J. H. Payne, of Bury, author of the "Bee-keeper's
Guide" introduced another glass. It has a three-inch hole in the
centre, the purpose of which is to tempt bees to produce additional
and larger stores of honey. It is to be used as follows:—When a bell
glass is half or quite filled, raise it, and place Payne's glass over the
hole of the stock-hive, with the filled glass on it, over the three-inch
hole. The bees will bring their combs through, and thus Mr. Payne
found that they would store more honey than if the bell glass were
removed and another empty one put in its place. Of course, the first
glass must be smaller in diameter than Payne's glass, so as to rest
upon it.
FLAT-TOPPED GLASS.
This is a glass super, to be placed on the hive in a similar way to
the bell glasses already alluded to. It has the advantages of being
straight at the sides, flat at top, and without a knob; so that when
filled it may be brought on to the breakfast table, inverted, on a plate.
The glass lid shown in the engraving forms a cover, and fits over
outside, so as not to interfere with the combs within. These flat-top
glasses, like those with a knob, have a hole through which a zinc
ventilating tube is inserted. Dimensions, six and three-quarter inches
wide, five inches high.
GUIDE-COMB FOR GLASSES.
In some of our previous allusions to the best mode of inducing
bees to commence working in glasses, we have recommended
attaching guide-comb. We will now more particularly explain how this
attraction can be best applied. We have already shown how bees
may be induced to make use of guide-combs fixed to bars, and the
same principle is applicable to glasses. These may be filled, with
great regularity, by adopting the following directions, which, we
believe, have never before appeared in print:—
Procure a piece of clean new empty worker honey-comb, which
has not had honey in it (because honey will prevent adhesion to the
glass); cut it into pieces of about three-quarters of an inch square.
Gently warm the exterior of the glass (this we find is best done by
holding the glass horizontally for a short time over the flame of a
candle); then apply one of the pieces of empty comb inside at the
part warmed, taking care, in fixing it, that the pitch or inclination of
the cells is upwards—in fact, place the guide-comb in the same
relative position that it occupied in the hive or glass from which it was
taken. There is some danger of making the glass too warm, which
will cause the comb to melt and the wax to run down the side,
leaving an unsightly appearance on the glass; this should be
carefully avoided, and a little experience will soon enable the
operator to determine the degree of warmth sufficient to make the
comb adhere without any of it being melted. It is hardly necessary to
state that only the very whitest combs ought to be used. A short time
should be allowed before changing the position of the glass, so that
it may cool sufficiently to hold the comb in its place. Six or eight
pieces may thus be fixed, so that, when the glass is filled, it will
present a star shape, all the combs radiating from the centre. The
annexed engraving shows the appearance of a glass as worked by
the bees, in which guide-combs were fixed in the manner described
above. The drawing was taken from a glass of our own filled after
being thus furnished.
In the Old Museum at the Royal Gardens, Kew, may be seen a
Taylor's glass, presented by us, some of the combs in which are
elongated on the outside to the breadth of six inches. We believe,
that not only does a glass present a much handsomer appearance
when thus worked—and will, on that account, most fully reward the
trouble of fixing guide-comb—but that more honey is stored in the
same space, and in less time than if the glass be placed on the hive
merely in a naked condition for the bees to follow their own devices.
This mode of fixing guide-comb does not solely apply to the
above-shaped glass, but is equally useful for all kinds of glasses. It is
introduced in connection with this glass because, from its having a
flat top and no knob, the regularity is more clearly apparent.
The working of bees in the bell glasses illustrates how tractable
their disposition really is, if only scope be allowed for the due
exercise of their natural instinct. They have no secrets in their
economy, and they do not shrink from our constant observation as
they daily pursue their simple policy of continuous thrift and
persevering accumulation. Yet it is only owing to the labours of
successive inventors that we are now enabled to watch "the very
pulse of the machine" of the bee-commonwealth:—
"Long from the eye of man and face of day.

Involved in darkness all their customs lay,
Until a sage well versed in Nature's lore,
A genius formed all science to explore;
Hives well contrived, in crystal frames disposed.
And there the busy citizens disclosed."
Murphy's Vaniere.

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CLINICAL CASE FORMAT: PART I

discarding the irrelevant in ormation—a undamental skill in clinical problem

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1 Labor (Latent Phase) 22

When selecting guide-comb, avoid combs with drone-cells; to fix

Front View of Bee House.

The folding; doors behind the bee-house have only to be opened,

BEE-HOUSE TO CONTAIN TWELVE HIVES

BEE-HOUSE TO CONTAIN NINE HIVES.

EVENING THOUGHTS IN JANUARY.

(Translated from the German by Adalbert Braun.)

How quietly they're sitting!

That all, indeed, are living

That in the dwindling store-room

Thus daily do I visit

Thank God! they all were humming

And yet what ardent longing

How would this anxious longing

In heat or cold that prattles

Ye bee-keepers can value

With e'en the richest bee-stand

Thus, her I love and honour,

Her kisses sweet removing

Mount Radford, Exeter. T. W. Woodbury.

ORNAMENTAL ZINC COVER.

This is a simple and inexpensive covering for any cottage straw

TAYLOR'S ZINC COVER.

This zinc cover, introduced by H. Taylor, Esq., for his cottage

TAYLOR'S BELL GLASSES.

These glasses have been introduced by Mr. Taylor, and are

"Long from the eye of man and face of day.

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