THE AGE OF WOMEN WHEN THE CA- PACITY FOR CHILD-BEARINp CEASES. BY FORDYCE BARKER, M.D., Professor of Clinical Midwifery and Diseases of Women in the Bellevue Hospital Medical College, etc. Read before the New York Medical Library and Journal Association, November 20, 1874. [REPRINTED FROM THE PHILADELPHIA MEDICAL TIMES.] THE period when the capacity for child-bearing ceases in women is often a subject of medico- legal inquiry; yet, up to the present time, the ques- tion is left very loose and undetermined in the stand- ard works on medical jurisprudence. I have several times been called upon to give an opinion on this point, and in this paper I shall give my reasons for expressing the belief that the limits of the capacity for conception and gestation in women can be de- fined with sufficient accuracy to warrant the medi- cal expert in the expression of a positive declaration. Yet so many wonderful and apocryphal stories may be found in the medical literature of the past, which can be and often are quoted as disproving the accu- racy of such a declaration, that it seems important to settle the question whether science can pronounce with authority that such pretended facts must be false. A zealous advocate, who feels that the in- terest of his client warrants him in bullying, by a rapid series of questions, in a loud tone of voice 2 as if to intimidate from lying, may irritate and embarrass a medical witness to a degree that will destroy the force of a well-considered and sound opinion. For example, the medical expert is asked such questions as the following : " Do you set your- self up as an authority on this subject ? Did you ever hear or read of Haller, one of the greatest lights in medicine that has lived in any age? Do you think that he made a false statement whdn he declared that he delivered one woman in her sixty- third and another in her seventieth year? Do you know anything of Tilt and Tanner as medical au- thors? What is your opinion of them? Now, will you say on your oath that they lie when they assert that Haller states that he did deliver two women at these ages? Did you ever hear of Dr. Benjamin Rush, one of the signers of the Declaration of In- dependence? Do you not think him rather a re- spectable man, who would be likely to speak the truth? Then are you ready to swear that he did not when he says that Ann Woods married after she was sixty years of age and gave birth to a child ten months afterwards? Did you ever hear of such a work as Beck's Medical Jurisprudence ? Do you pretend that 1'. Romeyn Beck in this great work states an untruth when he declares that Ann Cook, of Whitehall, in this State, at the age of sixty-four had a child, born in February, 1836?" A thorough knowledge of the literature of the sub- ject and of the physiological laws which must govern it, an imperturbable temper, and great care in giving direct and simple answers to direct questions, and in avoiding the appearance of being a partisan advo- cate, will best protect the medical witness from the confusion and embarrassment of a false position. Casper states " that every year cases come before us in which it is judicially inquired whether an 3 aged woman, in her present marriage, or in a sec- ond one about to be entered into by her, may yet probably have children. Usually these are women approaching their fiftieth year, if they are not al- ready far beyond it, and who have for long ceased to menstruate." * I suppose this question is a sub- ject of judicial inquiry much less frequently in this country ; yet every physician is liable to be called upon to testify in regard to this point. In two in- stances 1 have reason to believe that an opinion which I prepared at the request of eminent members of the legal profession served to avert scandalous litigation. In a third case, a woman said to be of weak mind and a confirmed opium-eater, wealthy by the rise of real estate in this city which she in- herited, married a second husband when she was forty-nine years of age. She had no children by her first husband. At the age of fifty-eight she asserted that she was pregnant, and persisted in this assertion for nearly a year. Subsequently her hus- band and herself declared that she gave birth to a child, while in the country, during the summer, and a nurse and two other women were ready *to swear to it, no physician being present at the time of the birth. Three months after this alleged de- livery she was one morning found comatose, and died a few hours after, the death being reported as due to apoplexy. The following summer the child died from cholera infantum. The husband claimed the property which she left, as heir to her child. This claim was contested by two nephews and the husband of a niece of the woman. The counsel for the contestants submitted to me a great array of medical opinion, which purported to show, from * Forensic Medicine. The New Sydenham Society, London, vol. iii. p. 260. 4 numerous examples found in medical literature, that women over fifty-eight years of age have given birth to children. Before the case came to trial, con- clusive evidence was found to establish the fact that the nurse, and not the old woman, was the mother of the child in question. Within the past year I have been called upon to give testimony in a case involving a very consider- able amount of property, the case turning upon the point whether it be possible for a woman after her sixty-seventh year to conceive and give birth to a child. It was with regret that I felt it my duty to give an opinion, and my reasons therefor, adverse to that of several of my respected confreres. My object in the present paper is to show that physiology and experience have determined the limits of the reproductive functions in women. It is generally assumed that the duration of the child- bearing capacitv is coincident with the duration of menstruation. Most writers on forensic medicine, and most medical witnesses in the cases in which I have been engaged, have referred to the numer- ous examples of menstruation prolonged beyond the usual periods of life as evidence that such women are capable of impregnation and gestation. While it is generally true that when menstruation ceases the ovaries are no longer capable of furnish- ing mature ova for fecundation, and the uterus no longer has the power of retaining and developing an ovum, yet, on the one hand, thousands of sterile women menstruate regularly and normally, while, on the other hand, there are great numbers of women who have conceived before they have men- struated, and others who have given birth to a child some years after menstruation has ceased. Many cases, whose authenticity is beyond question, can be found in medical literature which demonstrate 5 the truth of both assertions. I can furnish such which have come under my personal observation. A lady in perfect health, except that she never had menstruated, was married at twenty. In the ten years following her marriage, I attended her in eight confinements. In 1870 I received a letter from her written in Switzerland, where the family have been living for some years for the purpose of educating their children, saying that she had not been exposed to the danger of having more chil- dren since the birth of her last child, then six years old ; but that her husband was endeavoring to per- suade her that she must be now safe, as she never had been unwell. I wrote in reply that, as she never had menstruated before the birth of her chil- dren, I regarded her as an unsafe subject for me to commit myself to an opinion on this point. Another lady in this city, previous to her mar- riage, menstruated very scantily and irregularly. But in the twelve years since her marriage she has never menstruated, but she has given birth to ten children, and she is still keeping up her good work. As an example that conception and gestation may occur some years after menstruation has ceased, I will mention the case of a lady in this city who had borne five children, the last at the age of thirty- eight. She ceased to menstruate at forty-two. Her health had previously been delicate, but she now became strong and well, and increased in weight over thirty pounds. When more than forty-six, I was asked to examine her, as she had felt many of the usual symptoms of pregnancy. I expressed the opinion that she was five and a half months preg- nant ; and my diagnosis proved correct, as in due time she gave birth to the finest and largest child that she had ever borne. In this case there was no 6 motive for deception, and the result was a matter of family pride and rejoicing. In November, 1851, I was invited by Professor Willard Parker to see a very curious and interesting case, which had been examined by several obstetri- cians. A woman, whose character was good so far as known, five years a widow, represented her age as forty-seven, and that sh$ had not menstruated for three years. An abdominal tumor could be felt, reaching to the level of the umbilicus. An inces- sant convulsive movement of the abdominal integ- uments and muscles (phenomena sometimes, but rarely, associated with pregnancy, described by Velpeau,* but hardly alluded to by any other ob- stetrical writer) rendered obstetric auscultation quite impossible and abdominal palpation wholly unsat- isfactory. The mammary signs of pregnancy were negative. This woman gave birth to a child, sup- posed to be a little premature, the following March, and soon after died of puerperal fever. Ovulation and menstruation, although often co- incident, do not necessarily bear the relation of cause and effect, as has been supposed by many. Ritchief and others have demonstrated by autop- sies that ovulation does not always occur at the time of menstruation. remarks, "There is no proof and no probability that ovulation produces true menstruation. Certainly, ovulation, and even parturition, occurs in some women who have never menstruated. Menstruation is therefore an accidental and an incidental rather than an essential function, and it has no analogue in most of the lower animals. In itself considered, it is merely a flow of blood at * Meigs's Velpeau's Midwifery, Phil., 1852, p. 397. f Ovarian Physiology and Pathology, London, 1865. J Ovarian Tumors, New York, 1872, p. 529. 7 stated periods from the interior of the uterus, irre- spective of its connections and its causation." Ovulation is absolutely an essential function for conception and gestation : but menstruation is not. Hence the numerous cases reported by medical writers, and quoted in works on medical jurispru- dence, of a regular recurrent sanguineous flow from the genital organs in women over fifty-five years of age, no more demonstrate the possibility of concep- tion in such women than does the same apparent menstrual discharge in women who have had both ovaries removed, of which there are several authen- tic cases. When that physiological process takes place known as senile atrophy of the ovaries,-that is, when the ovaries diminish in volume, shrink up, and become wrinkled, the Graafian follicles disappear, the stro- ma becomes dense and non-vascular,-then ovula- tion ceases, and conception and gestation are no longer possible. All physiologists are in agreement in fixing the period of this change in woman as between forty and fifty. In a very exceptional number of women this change does not take place until one, two, three, or even four years later. This is proved not only by thousands of autopsical exam- inations, but also by the fact that not a single au- thentic case is known, of the slightest scientific value, where a woman over fifty-five years of age has given birth to a child, with the exception of Sarah, the wife of Abraham, in biblical history. Abraham was one hundred and Sarah was ninety years old when Isaac was born ; and it is said "it ceased to be with Sarah after the manner of women." It is not surprising that Sarah, when she heard the an- nouncement of her future pregnancy, "laughed within herself, saying, After I am waxed old shall I have pleasure, my lord being old also?" Accord- 8 ing to Scott's Commentary, "the name Isaac signi- fies laughter, and this child of promise was so named in remembrance of Abraham's believing and Sarah's unbelieving laughter." From the time of Pliny down to the present day, there have been many cases reported in medical lit- erature and quoted in works on forensic medicine, where women from fifty-eight up to eighty years of age are said to have given birth To a child. But in a scientific inquiry I hold that we are bound to reject all statements which are opposed to the universal experience of mankind, when the probabilities against the truth of the assertion are at least as a million to one, unless it be supported by such evidence as would be regarded as con- clusive in a court of law. Some of these reported cases have their only foundation in either tradition, travellers' tales, common rumor, or an anonymous paragraph in a newspaper or a magazine. Others again arise from a misquotation or a perversion of the original statement. The limits of this paper will not permit me to trace to the original source and analyze all of these cases, but I will briefly ex- amine those which seem to have been accepted gen- erally by writers on medical jurisprudence and by some recent obstetrical writers. One of the earliest cases alluded to by many is given on the authority of "Pliny the Naturalist." Montgomery* says, "Pliny records the case of Cornelia, of the family of Scipio, who at the age of sixty bore a son, who was named Volusius Sat- urninus." Tiltf makes a somewhat different state- ment, as follows: "Cornelia was confined of Vale- rius Saturnius in her sixty-second year." It is suf- * Cyclopaedia of Practical Medicine, London, vol. iii. p. 491; also Montgomery on Pregnancy, Phil., 1857, p. 260. f Change of Life, 2d ed., London, p. 18. 9 ficient to say, in regard to this, that the eldest child of Cornelia was born 163 b.c., and that Pliny was born 23 a.d. Consequently, one hundred and fifty years at least must have elapsed from the time of this extraordinary birth to the time when Pliny wrote ; and, as he gives no documentary evidence in proof of his statement, it is safe to infer that it was derived solely from tradition. Numerous writers assert that Massa, a physician of Venice (the name is variously spelled when quoted, as Marsa, Marra, Mansa), says "that he treated a woman for dropsy, who was really pregnant, he being deceived by her age, which was sixty." The writer referred to must be Nicholas Massa, of Venice, who died 1569. In his work,* in the " Epistola de aqua cutem seu hydrop," he speaks of a case in which a woman of sixty was treated for dropsy when she was pregnant, but he does not say that he was personally cognizant of the fact. Many obstetrical and forensic authors refer to Valescus de Tarenta as " mentioning a woman who continued to menstruate beyond sixty, at which age she bore her last child." Valescus de Tarenta was a native of Portugal, born in 1382, and practised medicine in Montpellier, France. His work, " Prac- tica quae alias Philonium dicitur," can be found in that remarkable and valuable collection of medical books, the library of the New York Hospital, and perhaps some one who can read mediaeval Latin with facility may take the trouble to ascertain exactly what he did say. The weight of the great name of Haller has been invoked in proof of the fact that women of advanced age have borne children. I find in many of the standard writers on this subject the assertion that * Epistolse Medicinales, Venet., 1549. 10 " Haller delivered one woman in her sixty-third and one in her seventieth year." This curiously illus- trates how books are filled with hasty, erroneous, and perverted quotations, for there is no evidence that Haller ever practised midwifery. He was born in Bern, 1708. In 1735 he was appointed physi- cian to the hospital in his native town, but in 1736, when he was twenty-eight years of age, he was made a professor in the University of Gottingen, and from this time he gave up the practice of his profession. All that Haller ever said in his writings on this sub- ject is as follows: "Women have been seen to bring forth in their fifty-fourth year, fifty-eighth, sixtieth, sixty-third, seventieth, and among my relatives was a child-bearing matron whose two sons born after their mother's fiftieth year, chosen into the senate, are living at the time of my writing this."* Caplibn is often quoted as an authority that women of an advanced age have borne children. But the only personal statement which he makes on this point is "that in Paris it passes for true that a woman in the street La Harpe gave birth to a daugh- ter at the age of sixty-three."f On which Casper makes the following comments : " Those acquainted with Paris well know the class of people living there: small shop-keepers, tradesmen, and the like. Are these observations possessed of the slightest scien- tific authenticity ?"J The case of Ann Woods, who is said by Dr. Ben- * Elementa Physiologiae, Bernse, 1765, tomus vii. pars ii. p. 141. I give the passage in the original, with the authorities which Haller cites: " Peperisse visa: sunt feminae anno 54(c), 58(d), 60(e), 63(f). 70(g), et inter consanguineas meas fuit patritia matrona, cujus duo filii post quinquagesi- mum matris annum nati in senatum adlecti supervivunt dum haec scribo." (c) Eph. Nat. Om., vol. vii. obs. 80. (d)Hist. de la Chirurg. (e)Plot. Natur. Hist, of Oxford. Valesc. de Tarenta. (f)Plot., Wallace, p. 64. (g)Salmut, Cent. iii. obs. 59. f Medecine Legale, Paris, p. 93. J Forensic Medicine. The New Sydenham Society, vol. iii. p. 260. 11 jamin Rush "to have given birth to a child after she was sixty years old," is often referred to; but the evidence of the truth of the story rests entirely upon the assertion of the old woman herself, "who called at his house to beg for cold victuals," and at this time she claimed to be ninety-six.* Another famous case, often quoted, is that of Ann Cook, of Whitehall, who is said to have had a child at the age of sixty-four, f This story originated in an anonymous communication to the Boston Medi- cal and Surgical Journal,\ and is entirely unsup- ported by any evidence. I think it wholly unnecessary for me to refer to various other reports of aged women who have given birth to children, which rest solely on paragraphs in newspapers and magazines, as these are of no scien- tific value. After the most careful and laborious research, I can find but one authentic case, based on the evi- dence of a respectable medical man, who carefully investigated the documentary proof of the fact, where a woman who has reached the age of fifty- five has given birth to a child. This case is re- ported by Dr. Davies, of Hertford, England.§ There are a considerable number of cases which must be accepted as authentic, as the evidence is conclusive, that women between the ages of fifty and fifty-four have borne children. 1 have per- sonally known three women over fifty years of age who have become mothers. One case, which came under my observation, is so curious that I may be pardoned for relating it, as it is well known to many now living in this city. * Rush's Essays, Philadelphia, 1798, p. 301. f Beck's Medical Jurisprudence, 10th ed., p. 246. J Vol. xiv. p. 79. | London Medical Gazette, vol. xxxix. 12 May 6, 1852, I attended a case of labor in St. Mark's Place, in consultation with the late Dr. Robson of this city. The labor was normal but tedious, and our patient was delivered of a daughter by the aid of the forceps. This lady had been mar- ried twenty-seven years, and this was her first preg- nancy. After the birth of the child, the husband showed to Dr. Robson and myself a family Bible, in which the birth 6T his wife was recorded as hav- ing been May 5, 1801. July 3, 1853, Dr. Robson having died, I at- tended this lady in her second confinement. The mother and both daughters (now married) are still living.* The question as to the age when the capacity for child-bearing ceases has been frequently brought before courts of law. In one instance only, so far as I can learn, it was decided that this is possible at the age of fifty-eight. Francois Fajat claimed an estate as heir to his mother. His claim was resisted on the ground that, according to the baptismal registry, his mother could not have been the legiti- mate heiress through whom the claim accrued, be- cause her alleged mother would have been in her fifty-eighth year, and this, it was contended, was beyond the age of child-bearing. The court re- ferred the case to the Academy, who, from the "Annals of Medicine," produced the apocryphal cases which I have before examined. The court admitted the legitimacy on the grounds that men- struation and conception had been known to occur * The husband, whose age was fifty-four when his first child was born, was for many years captain of a New York and Liverpool packet-ship. I asked him how he explained the curious fact that his wife had now for the first time become a mother. His answer was that " he had followed the sea for many years, until he had got money enough to live as comfortably as he wished, when he concluded to stay at home and 'tend to his family duties." 13 at periods even later than this.* This was in Paris, in 1754- The legitimacy of the claimant in the famous Douglas Peerage case, whose alleged mother at the time of his birth was in her fiftieth year, was de- cided in his favor. Until within a recent period, the English law has admitted "no presumption as to the time when a woman ceases to have children, though this enters into most other codes." f But at the present time the fact is otherwise. In the English Court of Chancery, the succession to a large property depended entirely on the question whether a woman at sixty years of age might have a child. The Attorney-General, Sir William Horne, stated that there was no such case satisfactorily re- corded ; and he offered to give up his client's title if any credible evidence could be produced in sup- port of an instance. But, as none was brought for- ward, he was deemed to have succeeded in proving his claim.J The English Court of Chancery seem now to have arrived at a definite conclusion as to the age at which a woman may be presumed to be past child-bearing. In re Widows' Trusts, Vice-Chan- cellor Malin& made an order for payment to two ladies respectively. One of the ladies was a widow, past fifty-five, the other a spinster, aged fifty-three years and eight months. In both cases the parties were entitled absolutely, subject to the contingency of having children.§ In Forty zal Forty (Feb. 1853), Vice-Chancellor Kindersley decided that an unmarried lady aged * Devergie, Medecine Legale, tom. i. p. 435; also Capenon, Medecine Legale, p. 93. f Beck's Medical Jurisprudence, vol. i. p. 653. J Tanner, Signs of Pregnancy, London, i860, p. 18 ; also London Medi- cal and Surgical Journal, vol. iii. p. 687. § 40 Law Journal Rep., N. S., 380. 14 fifty-three might be presumed to be beyond the age of child-bearing. Taylor remarks, " The question may be considered definitively settled. A woman who has passed the age of fifty-three is presumed in law to be past the age of child-bearing."* I am not aware that this question has ever been judicially settled in our American courts. But, in conclusion, I feel warranted in stating the proposi- tion that the laws of physiology, the experience of mankind, and the decisions of courts of law, jus- tify a medical witness in declaring that a woman over fifty-five years of age is past the period of child-bearing. * Taylor's Principles and Practice of Medical Jurisprudence, London, 1873, vol. ii. p. 306.