Niddah 27a ~ Delayed Interval Twin Births and the Unlikely (But Plausible) Survival of Yehuda and Chizkiyya

Today the Talmud recounts the survival of twin boys, Yehuda and Chizkiyya. When I first read the story, I considered it to be entirely fanciful. It was impossible, so it seemed to me, to have actually occurred. Then I read the science, and I changed my mind. Let’s see if it changes yours.

נדה כז, א

א"ר אבין בר רב אדא אמר רב מנחם איש כפר שערים ואמרי לה בית שערים מעשה ונשתהה ולד אחד אחר חבירו ג' חדשים והרי הם יושבים לפנינו בבית המדרש ומאן נינהו יהודה וחזקיה בני רבי חייא

Rabbi Avin bar Rav Adda says that Rav Menachem of the village of She’arim, and some say that he was from Beit She’arim, says: An incident occurred where one offspring remained in the womb after the other was born for three months, and both twins are sitting before us in the study hall. And who are they? They are Yehuda and Chizkiyya, the sons of Rabbi Chiyya.

Delayed Interval births - what you need to know

When you look at the medical literature, it turns out that there are many case reports of delayed-interval twin births. This is probably because the number of multiple pregnancies has increased due to the expansion of assisted reproductive technology. In nearly all, the first twin died soon after delivery because it is too premature to survive.

Here is just one example. Last year a group from the Department of Clinical and Experimental Medicine at the University of Pisa in Italy published a case report with a very lengthy title: Delayed delivery of the second twin: Case report and literature review of diamniotic dichorionic twin pregnancy with very early preterm premature rupture of membranes. A mother went into very early labor and delivered the first of two twins at about 26 weeks’ gestation. The second twin remained in her uterus, and was delivered 29 days later by cesarean section. The first very premature twin died, but happily the second survived and at 6-month follow-up, “no neurological, cardiac or other defects could be detected.”

A 2016 systematic review found 13 articles reporting a total of 128 cases of delayed-interval twin births. It reported that the second born twin had a significantly lower mortality risk compared to the first born (relative risk = 0.44, 95% confidence interval = 0.34 – 0.57, P<0.0001,) which makes sense since the second twin had the benefit of a longer period of uterine gestation.

Results of individual studies, mortality of the second born versus the first born. From Feys S. Jacquemyn Y. Delayed-interval delivery can save the second twin: evidence from a systematic review. Facts Views Vis Obgyn, 2016, 8 (4): 223-231.

Interval twin births - the world Record

There is even an official world record for delayed-interval twin births. According to Guinness World Records, the longest verified interval between the birth of twins is 87 days (and 1 hour 45 minutes). Twin girls Amy Ann and Kate Marie Elliot were born 87 days apart, at Waterford Regional Hospital in County Kilkenny, Ireland. Amy was born prematurely on 1 June 2012 and Kate followed on 27 August. Because Amy Ann was born at 09:16 and Kate Marie at 11:01, the exact interval is 87 days, 1 hour and 45 minutes. That’s just shy of three months. Just like the story in the Talmud.

Actually, there is a report that in 2018 this record was beaten, though I’d be careful about believing what you read in perhaps the smuttiest paper in Britain, The Sun. But here it is anyway. And note that the twins were born just over three months apart.

Mum Oxana went into labour initially at just 26 weeks pregnant and gave birth to Liana prematurely on November 17, 2018. She weighed just 2lbs. Three months later, she finally gave birth to Leonie - four days after her initial due date. A spokeswoman for Holweide hospital in Cologne said: "After the birth of the first twin, the cervix closed again and the unborn sister could remain in the womb.” As contractions ceased, doctors decided that Oxana could carry her second baby girl to term.

Maternity chief Dr Uwe Schellenberger said: "The conditions were very good as well due to the existing second placenta and we wanted to try to let the second child mature as long as possible in the womb." Leonie was born a total of 97 days difference with her twin sister Liana and was born weighing 8.1lbs. Dr Schellenberger said: "It's also a rare case for our maternity clinic, but it was not the first time that twins were born on different days at the Holweide hospital. "But the time difference of 97 days is unique for us and also special worldwide."

According to the hospital, the girls may have broken a world record. "Such a 'two-time twin birth' is very rare worldwide," the spokeswoman explained. "According to our own research, twins with a time difference of 87 days were born in Ireland in 2012." Liana spent her first few weeks in a neonatal care unit at the hospital where she stayed until she was strong enough to go home.Both girls now weigh around 12.5lbs and have developed well.The spokeswoman said that they've both been reunited at their family home and are set to grow up healthy.

What would it have taken for Yehuda and Chizkiyya to survive?

In its English translation, the Artscroll Talmud introduces this story calling it a “fantastic incident.” If by “fantastic” it means “based on fantasy” or “not real,” it is mistaken. If however, it means “so extreme as to challenge belief” well then it is correct. It is indeed an extremely unlikely story, but not an impossible one. Here is what it would take to have actually occurred.

1. The first born twin would have had to be born at around six months gestation. Even today, with neonatal intensive care units, incubators, respirators, antibiotics and specialist staff, this is the very limit of survivability. The mortality rate in babies born between the 23rd and 25th week is 32%.

2. Next, the mother would have had to survive the preterm premature rupture of the amniotic membranes which carries a risk of 17-52% of introducing an intrauterine infection, and a risk of 4-22% of causing maternal sepsis.

3.Then the mother would have had to carry the second twin to a full-term birth, and that twin must survive.

4. Finally - and this is important - the Talmud lets us know that the boys were “sitting in the study hall.” In other words, they both had a fairly normal cognitive ability, which in very premature infants is often not the case.

Tosafot Agrees - it is really rare

The chances of all this happening are very low. In fact the medieval compendium of commentaries on the Talmud known as Tosafot makes this very point (Niddah 26b ד’ה ילדה):

ילדה ואח"כ הפילה שליא אפי' עד י' ימים אין חוששין לולד אחר. אע"ג דאמר לקמן דנשתהא הולד שלשה חדשים מ"מ לא שכיח וכל כמה דלא חזינן לא חיישינן

Even though the Talmud states that “one offspring remained in the womb after the other was born for three months,” this is not common. And when something is so rare that it almost never happens, it may [for practical purposes] be ignored.

But a very low likelihood of something happening does not make it impossible. The three month delay in the birth of the boys was indeed scientifically possible. I hope Yehuda and Chizzkiya realized just how lucky they were.

““We feel so blessed to be here,” their mother said. “The only thing that’s gotten me through this... is to say, ‘God is in control,’” she noted.
”

— Kristen Miiler, mother of twins born five and a half weeks apart. See "Doctors stunned by rare twins born more than five weeks apart." Washington Post April 7, 2016

Niddah 25b ~ Four Cases of Torture & Coerced Testimony

In today’s page of Talmud there is a question about the ritual status of a gestational sac that was expelled by a woman who had a miscarriage. Mar Shmuel, (died circa 254CE) who was perhaps the most famous physician in the Talmud, issued a ruling that demonstrated his ability to date the age of a miscarriage to within a day.

נדה כה,ב

 והא ההוא שפירא דאתאי לקמיה דמר שמואל אמר הא בר ארבעין וחד יומא וחשיב מיומא דאזלא לטבילה עד ההוא יומא ולא הוה אלא ארבעין יומין ואמר להו האי בנדה בעל כפתיה ואודי שאני שמואל דרב גובריה

There was an incident involving a certain gestational sac that was brought before Mar Shmuel, and Shmuel said: This embryo is forty-one days old. And Shmuel subsequently calculated the amount of time that had passed from the day that the woman went to perform immersion in a ritual bath until that day, and it was only forty days.

And he said to the local court: This husband engaged in intercourse with his wife when she was a menstruating woman. They bound the husband and he confessed. Since Shmuel was so proficient in embryology, why was he unsure about the halakhic status of a gestational sac? The Gemara answers: Shmuel himself is different, as his strength, i.e., his proficiency, was great. His general ruling that the halakhic status of a gestational sac is uncertain applies to people who are not as proficient as he is. 

As a result of his calculation, Shmuel accused a man of having intercourse with his wife when she was ritually impure. He was bound and confessed, (though it is not clear who was ordering the binding).

Other cases of coerced Confessions

We have previously read of other examples in which torture (or according to some, the threat of torture) was used to obtain a confession of a crime. In the first two, Abaye suspected that bills of sale had been forged. "כפתיה ואודי" - Abaye  bound the suspects to a post, and they confessed. In the third case it was Rava who suspected that his own signature and that of the elderly Rav Acha bar Adda had been forged. Rava too, bound the suspect to a post, after which not only did the suspect confess to forging both signatures, but he went on to explain how he had forged that of the elderly Rav Acha, whose hands had a tremor. 

בבא בתרא קסז, א

 אנחי ידאי אמצרא ואמרי לה קם אזרנוקא וכתב

I placed my hands on the rope of a bridge while signing. Others say he stood on a skin bottle and signed.

Another case is found in the tractate Bava Metzia (24a). There, we read that Mar Zutra “The Pious”  had coerced a student to confess to his crime.

בבא מציעא כד, א

מר זוטרא חסידא אגניב ליה כסא דכספא מאושפיזא חזיא לההוא בר בי רב דמשי ידיה ונגיב בגלימא דחבריה אמר היינו האי דלא איכפת ליה אממונא דחבריה כפתיה ואודי

Mar Zutra the Pious was involved in an incident in which a silver cup was stolen from his host. Later, Mar Zutra saw a certain student wash his hands and dry them on his friend's garment. Mar Zutra said: "this is the one who stole the cup, for he has no consideration for his friend's property. Mar Zutra bound the student to a post and coerced him, and he confessed to the crime (Bava Metzia 24a).

He was bound and he confessed

Courtesy of Wikimedia.

The phrase that is used in all four cases is כפתיה ואודי "they bound him and he confessed." The root of the word to bind is כפת, which is used in rabbinic literature to mean to tie or to bind. Rabbi Asher ben Yechiel (Germany ~1250-1327), known as the Rosh, is certain that the suspect was tortured. In his commentary on the passage in Bava Metzia, he wrote וכפתיה בשוטי עד דאודי "he flogged him with rods until he confessed." (As in חושך שבטו שונא בנו ואהבו שחרו מוסר "spare the rod and spoil the child," from Proverbs 13:24.) Rabbi Betzalel ben Avraham Ashkenazi (Israel ~1520-1594) in his commentary to Bava Metzia called Shitah Mekubetzet agrees that coercion was used, although he is unsure if it was physical or psychological:

כפתוהו ואודי. יש מפרשים כפתוהו על העמוד והלקוהו בשוטים. ויש מפרשים כפתיה בדברים שנדוהו אם לא יודה האמת

Some explain that he was tied to post and flogged. Others explain that he was verbally coerced (and threatened with excommunication) until he confessed.

False Confessions

In a 2010 paper published in the Stanford Law Review, Brandon Garett notes that DNA testing has now exonerated over forty people who falsely confessed to rapes and murders. He wonders how an innocent person could convincingly confess to a crime he never committed. For example, in 1990  Jeffrey Deskovic a seventeen-year-old, was convicted of rape and murder. Deskovic was a classmate of the fifteen-year-old victim, had attended her wake, and was eager to help solve the crime. During one of several police interrogations he “supposedly drew an accurate diagram,” which depicted details concerning “three discrete crime scenes” which were not ever made public. "In his last statement, which ended with him in a fetal position and crying uncontrollably," wrote Garrett, "he reportedly told police that he had “hit her in the back of the head with a Gatoraid [sic] bottle that was lying on the path.” Police testified that, after hearing this, the next day they conducted a careful search and found a Gatorade bottle cap at the crime scene."

“Scholars increasingly study the psychological techniques that can cause people to falsely confess and have documented how such techniques were used in instances of known false confessions.”

— Garrett, B.L. The Substance of False Confessions. Stanford Law Review 2010. 62 (4): 1051-1119.

Deskovic was convicted of rape and murder and served more than fifteen years of a sentence of fifteen years to life. Then in 2006, new DNA testing not only excluded him, but also matched the profile of a murder convict who subsequently confessed and pleaded guilty. So how did Deskovic know all the details of the crime to which he confessed? Here is what the District Attorney noted in the post-exoneration inquiry:

...Given Deskovic’s innocence, two scenarios are possible: either the police (deliberately or inadvertently) communicated this information directly to Deskovic or their questioning at the high school and elsewhere caused this supposedly secret information to be widely known throughout the community.

Another paper, this time in the North Carolina Law Review, analyzed 125 cases of "proved interrogation-induced false confessions, which, the authors note with some pride, is "the largest cohort of interrogation-induces false confession cases ever identified and studied in the literature." It makes terrifying reading.  

It is of course really hard to study in the laboratory the psychological effects of torture and coercion and how they produce false confessions.  But scientists try anyway. For example, a very recent paper from a team from the New School for Sociological Research in New York and the University of California studied the effect of sleep deprivation on false confessions.  When compared to those who had rested, participants were over four times more likely to sign a false statement if they were deprived of one night's sleep.  In another recent peer-reviewed paper, (Constructing Rich False Memories of Committing Crime) psychologists used suggestive retrieval techniques on some rather nice Canadian undergraduates. They found that up to 70% of those interviewed 

were classified as having false memories of committing a crime (theft, assault, or assault with a weapon) that led to police contact in early adolescence and volunteered a detailed false account. These reported false memories of crime were similar to false memories of noncriminal events and to true memory accounts, having the same kinds of complex descriptive and multisensory components.

They continue: 

Our finding that young adults generated rich false memories of committing criminal acts during adolescence supports the notion that false confessions and gross confabulations can take place within interview settings. The Innocence Project has shown that about 25% of false convictions are attributable to faulty confession evidence...The kind of research presented here is essential in the quest to help prevent memory-related miscarriages of justice.

False Memories Become Real

In a recent article in The New Yorker, Rachel Aviv reported on the remarkable story of how DNA evidence exonerated six convicted killers. Despite this, two of them had detailed memories of the killing that they didn't commit. One was a woman named Ada Taylor who confessed to a woman’s murder in 1989 and for two decades believed that she was guilty.

She served more than nineteen years for the crime before she was pardoned. She was one of six people accused of the murder, five of whom took pleas; two had internalized their guilt so deeply that, even after being freed, they still had vivid memories of committing the crime. In no other case in the United States have false memories of guilt endured so long. The situation is a study in the malleability of memory: an implausible notion, doubted at first, grows into a firmly held belief that reshapes one’s autobiography and sense of identity.

Of course murder is not the same as forging a document, but the lesson for those in criminal justice is the same. People confess to all sorts of things - especially when they are coerced or tortured- and can even forge false memories of the crimes of which they were accused.  

Permitted Coercion in Jewish Law

In the Code of Jewish Law, the שולחן ערוך, the passage in Bava Basra is the basis for the legal right to extract a confession from a person suspected of forging business documents.

שולחן ערוך חושן משפט מב, ג

ואם צריך לכוף בעל השטר ולהכותו כדי שיודה יעשה כדי שיוציא הדין לאמיתו

If it is necessary, the owner of the document (who is suspected of forgery) may be beaten in order for him to confess and the truth to come out...

This certainly made me feel uncomfortable, but let's put this into some context. Torture has been a part of many judicial systems, and was a feature of  Roman law.  Perhaps most notoriously it was used by the Inquisition, after Pope Innocent IV issued a papal bill Ad extirpanda in 1252 which authorized its use by the Church.  Closer to home, the US has recently grappled with, and condemned cases in which the Central Intelligence Agency tortured prisoners, as the Senate Select Committee on Intelligence (partially) revealed in 2014. But among the thousands of legal decisions in the Babylonian Talmud, there are only four rabbis who are named as having tortured or coerced a suspect to confess. And that low number, though it is not zero, should provide us with some solace.  

Niddah 24a ~ Halachic Reality and Anatomic Reality: Treif People and Treif Animals

In tomorrow’s page of Talmud we read of a dispute about survivability of an infant with a birth defect. According to Rav Zakkai, an infant lacking legs from the knees downward cannot live, and is classified as a treifah. Rav Yannai declared that such a child could live, but agreed that it is classified as a treifah. Rav Yannai believed that only a birth defect that included the urinary opening was severe enough to be incompatible with life. In both cases the child is declared a treifah, but what is in dispute is the prognosis of such a treifah.

נדה כד,א

בין רבי זכאי לרבי ינאי איכא בינייהו טרפה חיה מר סבר טרפה חיה ומר סבר טרפה אינה חיה

The difference between the opinion of Rabbi Zakkai and that of Rabbi Yannai is whether a tereifa [can survive beyond twelve months]. One sage, [Rabbi Yannai,] holds that a tereifah can survive [beyond twelve months. Therefore, although one whose legs were removed until above the knee has the status of a tereifa, if a woman discharges a fetus of this form she is impure. Only if the fetus lacks legs until his orifices is the woman pure, as such a person cannot survive.] And one sage, [Rabbi Zakkai], holds that a tereifah cannot survive [beyond twelve months]. …

Treifah Animals

We have previously met the concept of treifah when we studied Chullin and the laws of rural slaughter called shechitah. Here is a reminder, from the start of the third chapter of Chullin (42a) where we took a deep dive into animal anatomy.

אלו טרפות בבהמה נקובת הוושט ופסוקת הגרגרת ניקב קרום של מוח ניקב הלב לבית חללו נשברה השדרה ונפסק החוט שלה ניטל הכבד ולא נשתייר הימנו כלום הריאה שניקבה או שחסרה ר"ש אומר עד שתינקב לבית הסמפונות ניקבה הקבה ניקבה המרה ניקבו הדקין הכרס הפנימית שניקבה או שנקרע רוב החיצונה רבי יהודה אומר הגדולה טפח והקטנה ברובה המסס ובית הכוסות שניקבו לחוץ נפלה מן הגג נשתברו רוב צלעותיה ודרוסת הזאב רבי יהודה אומר דרוסת הזאב בדקה ודרוסת ארי בגסה דרוסת הנץ בעוף הדק ודרוסת הגס בעוף הגס זה הכלל כל שאין כמוה חיה טרפה

These wounds constitute tereifot in an animal,rendering them prohibited for consumption:

1. A perforated esophagus, where the perforation goes through the wall , 

2. or a cut trachea.

3. If the membrane of the brain was perforated, 

4. or if the heart was perforated to its chamber; 

5. if the spinal column was broken and its cord was cut; 

6. if the liver was removed and nothing remained of it…

7. a lung that was perforated

8. or a lung missing a piece….

9. If the abomasum was perforated

10. or the gallbladder was perforated, 

11. or the small intestines were perforated, it is a tereifa…

This is the principle: Any animal that was injured such that an animal in a similar condition could not live for an extended period is a treifa, the consumption of which is forbidden by Torah law. 

The original meaning of the term treif in the Torah is torn, and it describes a domestic animal that was attacked by a wild animal and suffered an injury that led to its death.

“וְאַנְשֵׁי־קֹ֖דֶשׁ תִּהְי֣וּן לִ֑י וּבָשָׂ֨ר בַּשָּׂדֶ֤ה טְרֵפָה֙ לֹ֣א תֹאכֵ֔לוּ לַכֶּ֖לֶב תַּשְׁלִכ֥וּן אֹתֽוֹ׃
You will be holy people to Me: you must not eat flesh torn by beasts in the field; you shall cast it to the dogs.”

— Exodus 22:30

But the rabbis of the Talmud greatly expanded this category - hence the list in this Mishnah in Chullin. Elsewhere in Chullin (57b) there is a dispute as to the prognosis of living animal that has been declared treif. According to Rav Hunna, if an animal is treif, by definition it cannot live for longer than a year (אמר רב הונא סימן לטרפה י"ב חדש). But there are other opinions. The great editor of the Mishnah, Rabbi Yehudah HaNassi held that a treifa is destined to die within 30 days, while a berasia states that a treif animal cannot give birth (leaving open the question about male animals).

““Jason Marcus, chef and owner of the new Traif restaurant on S. Fourth Street in Williamsburg, says the name is just cheeky, not a slap at his mostly Kosher eaters.”

“But [the name] really represents our philosophical view of how restaurants should be free of rules. We’re just people who live for good food.””

It is generally agreed upon that list in Chullin detailed the kinds of lesions that would be fatal within a year. And that’s when the problems begin. Some of them are certainly likely to be fatal. For example a perforated esophagus (נקובת הוושט) leads to mediastinitis, an inflammation of the chest cavity. And that is commonly fatal. If the animal swallows something sharp it can pierce not only the esophagus, but the membranes that surround the heart, called the pericardium. Way back in 1955 - at the start of the era of antibiotics - The Australian Veterinary Journal published a case series of twenty-one dairy cows that developed traumatic pericarditis. “Fifteen cases were treated with sulphonamide [an antibiotic] and six were not. ” The six animals untreated cows all died, and even among the cows treated with antibiotics, almost half died. So yes, some lesions recorded in the Mishanh (and later refined in the talmudic discussion which follows) are indeed fatal.

The Case of Serachot

But other lesions that render an animal treif are certainly not fatal. Take for example lung adhesions, called סרחות (serachot, or sircha in the singular), which are discussed elsewhere in the tractate Chullin (46b et. seq). These adhesions are fibrous tissues that may run between different lung lobes, or between the lungs and the rib cage. They are common and are caused by a number of conditions, including trauma or previous infections. Many kinds of serichot render an animal treif. But lung adhesions are certainly not lethal. Animals and humans live quite happily with them. In fact this doctor recently told me that the presence of lung adhesions does not prevent lungs from being donated and used for a lung transplant. Now, if they are used in that delicate situation, they most certainly do not have a fatal defect, or anything even close.

the case of the missing liver (and the missing heart)

Opening paragraph of the famous responsa on “the chicken that had no heart”. From שו׳ת חכם צבי, Amsterdam 1712.

Equally puzzling to the modern reader is the sixth category in the Mishna’s list: ניטל הכבד ולא נשתייר הימנו כלום - if the slaughtered animal was found to have no liver. Here’s the thing: an animal cannot live without a liver. If a healthy looking cow - or indeed any cow -was well enough to be slaughtered, it must have had a liver. So this is not an example of a treif animal - it’s an example of one that could not possibly have existed. But don’t take my word for it.

In 1709 the great rabbi of Hamburg, Zevi Ashkenazi, (better known as the Chacham Zevi, after the name of his responsa) was asked the following question. A young woman had opened a slaughtered chicken to remove the unwanted entrails, while her cat sat at her feet “waiting patiently for anything that may fall to the ground.” To her great surprise, the young woman found that the chicken did not have a heart, and so assumed the bird was treif. Not so, claimed her mother, who apparently owned the chicken. The cat must have eaten it, when it was thrown to the ground together with the entrails. The young women was however quite adamant, and insisted she had never fed anything that resembled a heart to the cat. The bird had been perfectly healthy before it was slaughtered, eating and drinking like any other healthy chicken, (וגם בעודנה בחיים חיותה היתה חזקה ובריאה ובכל כחה לאכול ולשתות). The question of the kashrut of the bird was brought to the local rabbis, who declared it to be treif, on the basis that while alive, it had no heart.

The Chacham Zevi was asked to weigh in on the matter. “It is absolutely clear to any person who has a wise heart” he wrote, apparently enjoying the play on words, “or who has a brain in his skull, that it is impossible for any creature to live for even a moment without a heart…Clearly, the heart fell out when the bird was opened, and that cat ate it…It is obvious that the chicken is permitted” Strike one for common sense. You would think. But not so fast. This answer of the Chacham Zevi engendered one of the great halachic disputes of the eighteenth century. In one corner, the Chacham, and in the other at least four leading rabbinic figures who vehemently opposed this ruling: Naphtali Katz of Frankfurt, Moses Rothenburg, David Oppenheim (who was the Chief Rabbi of Prague, no less) and Jonathan Eyebeschuetz (who spent much of his later life fighting halachic battles against Rabbi Yaakov Emden, who was the son of the Chacham Zevi). It got nasty, but that’s a story for another day.

Halachic Reality

No bird or animal can live without a heart, and none can do so without a liver. So there can be no case, like the one in the Mishnah, in which a healthy living animal was slaughtered and found to be without a liver.

Some of the categories of treifot overlap with conditions that are indeed incompatible with life. Others are perfectly innocuous and compatible with a long and healthy life. And a few make no sense given what we know about animal physiology. But none should be thought of as describing an anatomical reality. They describe instead a halachic reality, a reality that reflected a world some 1,500 years ago. And while our understanding of physiology has changed, these halachic classes remain a fixed part of Jewish tradition. Here is the great Maimonides, who was obviously troubled by the chasm that sometimes exists between halacha and facts.

רמב’ם משנה תורה הלכות שחיטה י, יג וְכֵן אֵלּוּ שֶׁמָּנוּ וְאָמְרוּ שֶׁהֵן טְרֵפָה אַף עַל פִּי שֶׁיֵּרָאֶה בְּדַרְכֵי הָרְפוּאָה שֶׁבְּיָדֵינוּ שֶׁמִּקְצָתָן אֵינָן מְמִיתִין וְאֶפְשָׁר שֶׁתִּחְיֶה מֵהֶן אֵין לְךָ אֶלָּא מַה שֶּׁמָּנוּ חֲכָמִים שֶׁנֶּאֱמַר (דברים יז יא)"עַל פִּי הַתּוֹרָה אֲשֶׁר יוֹרוּךָ

Each one of these lesions that were declared treif remain so even if modern medicine can demonstrate that some of them are not actually fatal, and that it is indeed possible to live despite them. Rather we must follow these rabbinic categories, as the Torah states“ You shall act in accordance with the instructions given you and the ruling handed down to you; [you must not deviate from the verdict that they announce to you either to the right or to the left.]

In more recent times, Rabbi Avrohom Yeshaya Karelitz, better known as the Chazon Ish, also addressed this question. “We see today” he wrote, “that very often surgeons operate on the abdomen of a person [with an injury like one found in a treif animal], and he is completely cured, and lives a long life.” But this does nothing to change the way we view the categories of treif. These depend solely on what was decided by the rabbis of the Talmud, and no modern findings can change them.

[Repost from here.]

Niddah 23b ~ Mourning for a Lost Fetus

The Talmud has spent much time discussing the various forms that the content of a miscarriage might assume, and how this determines the ritual purity of the mother (or indeed the the status of the deceased fetus). It all began a couple of pages ago with this Mishnah:

נדה כא,א

המפלת חתיכה אם יש עמה דם טמאה ואם לאו טהורה ר' יהודה אומר בין כך ובין כך טמאה המפלת כמין קליפה כמין שערה כמין עפר כמין יבחושין אדומים תטיל למים אם נמוחו טמאה ואם לאו טהורה המפלת כמין דגים חגבים שקצים ורמשים אם יש עמהם דם טמאה ואם לאו טהורה המפלת מין בהמה חיה ועוף בין טמאין בין טהורין אם זכר תשב לזכר ואם נקבה תשב לנקבה ואם אין ידוע תשב לזכר ולנקבה דברי רבי מאיר וחכמים אומרים כל שאין בו מצורת אדם אינו ולד

…In the case of a woman who discharges an item similar to a shell ,or similar to a hair ,or similar to soil,or similar to mosquitoes ,if such items are red, she should cast them into water to ascertain their nature: If they dissolved ,it is blood, and the woman is impure with the impurity of a menstruating woman; and if not, she is pure.

In the case of a woman who discharges an item similar to fish or to grasshoppers, repugnant creatures, or creeping animals, if there is blood that emerges with them, the woman is impure with the impurity of a menstruating woman. And if not, she is pure.

With regard to a woman who discharges tissue in the form of a type of domesticated animal, undomesticated animal, or bird, whether it had the form of a non-kosher species or a kosher species, if it was a male fetus, then she observes the periods of impurity, seven days, and purity, thirty-three days…And if the fetus was a female, the woman observes the periods of impurity, fourteen days, and purity, sixty-six days…

And if the sex of the fetus is unknown, she observes the strictures that apply to a woman who gave birth both to a male and to a female. This is the statement of Rabbi Meir. And the Rabbis say: Any fetus that is not of human form is not regarded as an offspring with regard to observance of these periods, and she is permitted to engage in intercourse provided that she does not experience a discharge of uterine blood.

It all makes for very technical and detached reading, and quite honestly I have no idea to what shapes these refer. Over the decades as an emergency physician I have probably treated a several hundred women who came to the ED with an active or completed miscarriage, and never once did I see a bird, fish, or snake in the products of conception. I did however, meet a lot of sad and frightened mothers.

On today’s page of Talmud we finally discuss another aspect of the loss of a pregnancy: the emotional. Here is Rava, who explains that a fetus shaped like an animal does not preclude a later son born from the same mother to be considered as a firstborn. This is because the father would not mourn over such a misformed fetus:

נדה כג,ב

דאמר קרא [דברים כח] ראשית אונו מי שלבו דוה עליו יצא זה שאין לבו דוה עליו

“By giving him a double portion of all that he has; for he is the first fruits of his strength [ono];the right of the firstborn is his” (Deuteronomy 21:17). It is derived from the verse that the status of a firstborn applies only to a son over whose death a father would mourn.The word “ono” is interpreted homiletically based on its similarity to the word “onen”, acute mourner. This offspring that has the form of an animal is therefore excluded, as its father’s heart would not mourn over its death.

It’s the only time that the Talmud considers any emotional aspect of the loss of a pregnancy, and it hardly a surprise that when it does, it is the father’s emotions that are of relevance, rather than the mother’s. The Talmud is, after all, a record of how men viewed things. Rashi understands Rava’s statement as primarily legal rather than emotional. The father mourns, not because of the loss of a growing fetus, but because “he considers the question of inheritance.”

מי שלבו דוה עליו - לב אביו מתאבל על מותו הוא דחשיב לענין נחלה:

His heart mourns: The father’s heart mourns over the death of the fetus because he considers the question of inheritance

The epidemiology of Miscarriage

A miscarriage is a pregnancy that ends spontaneously before the fetus has reached a viable gestational age. There is no hard cut off, but this usually equates both clinically and legally to a human pregnancy that ends before 24 weeks of gestation, and as a review article on the epidemiology and medical causes of miscarriage pointed out, “human reproduction is extraordinarily wasteful.” One estimate is that “78% of fertilized eggs fail to result in a live birth and that the vast majority of these losses occur before the clinical diagnosis of pregnancy.” In other words, most women loose a pregnancy and never know they were even pregnant. Others suggest the rate of miscarriage is about 15-20%, generally occurring before 12 weeks gestation. Whatever the actual number, chances are that either you have had a miscarriage, or you know someone who has. We are blessed with four children. Our first pregnancy ended in a miscarriage.

“Sporadic miscarriage is the most common complication of pregnancy, and one in four of all women who become pregnant will experience pregnancy loss. The vast majority are early, occurring well before 12 weeks of gestation... The incidence of clinically recognizable miscarriage in general population studies has been consistently reported as 12-15%- but this figure is just the tip of the iceberg of total reproductive loss.”

— Regan L. Rai R. Epidemiology and the medical causes of miscarriage. Bailliere's Clinical Obstetrics and Gynaecology 2000. 14 (5) .839-854.

The emotional cost of miscarriage

Since many women turn to the emergency department when they have a miscarriage, let’s start with an old paper looking at loss and grief in this population, a consecutive sample of 44 women. About three weeks later 82% felt a sense of loss, and two thirds “experienced some limitation with daily functioning.” Importantly, even the mothers who did not want the pregnancy experienced a feeling of loss.

A Swedish study published last year looked at a larger population of 103 women and 78 of their male partners. They used a few different tools, including the Revised Impact of Miscarriage Scale (RIMS), the Perinatal Grief Scale (PGS) and the Montgomery Asberg Depression Rating (MADRS-S). As measured by all of these tools, the emotional experience of the miscarriage was more pronounced in women. They were more likely to describe the miscarriage as resulting in “isolation or guilt,” and a “devastating event.” For the women, active grief and coping difficulties were reduced after four months, but the feeling of despair remained the same. For the men, all three factors, (active grief, difficult coping and despair) were reduced after four months compared to one week. Women without children, women who had experienced a previous miscarriage and women undergoing infertility treatment showed significantly more grief than women with previous children. The researchers also noted that the fact the women had more negative emotional consequences after a miscarriage than men can affect the relationship of the couple, “and therefore, the men should not be neglected during treatment of miscarriage.”

And things can quickly worsen. The overall risk for an episode of major depressive disorder following a miscarriage is about 2.5 times that of other women. Specifically, 11% of women who miscarry experienced an episode of major depressive disorder compared with about 4% of other women.

How about the fathers?

Since Rava specifically addressed the mourning process in a father, let’s look at a study of the psychological impact of stillbirth specifically on fathers, published in the British Journal of Psychiatry in 2006. It questioned 38 pregnant couples whose previous pregnancy had ended in stillbirth, and compared them with 38 pair-matched controls. The couples were assessed six weeks, six months and one year after the loss. It was a small study, so caution is needed in generalizing, but it found that

1. Fathers experienced higher levels of depression than controls across all assessments.

2. Mothers had higher levels of psychological symptoms than fathers at every assessment, although the difference did not reach the level of significance.

3. Symptoms largely remit after the birth of a live child, although mothers continue to be more vulnerable than fathers to ongoing psychological morbidity. 

4. Parents’ levels of symptoms to run in tandem rather than for one of the partners to ‘carry’ the burden of symptomatic distress for both parents, or for one of the partners (typically the father) to feel that they have to deny their grief in order to remain strong in the face of the other’s distress.

Finally, the researchers found that for fathers there was a trend for better outcomes associated with conceiving again within a year of the stillbirth. “It is possible that these are chance findings,” they wrote, “but it is also possible that fathers and mothers have different needs in relation to this decision. Whereas mothers need time to mourn and recover before becoming pregnant again, fathers’ levels of depression and anxiety may increase as more time elapses before there is a real prospect of becoming a parent again. If this is the case, then there are implications for the advice that parents should be given about the timing of a subsequent pregnancy in the best interests of both partners.”

Experiences of miscarriage after one week and four months. Three questionnaires, the revised impact of miscarriage scale (RIMS), the perinatal grief scale (PGS) and the Montgomery–Asberg scale (MADRS-S) was used for measurements after one week and four months for women (n = 64) with miscarriage and their male partner (n = 64). For comparisons between different time points, Wilcoxon’s Signed Ranks Test was applied. For comparisons between men and women, Mann U-Whitney’s test was applied, P < 0.005 was considered significant difference. From Volgsten, H. Jansson C. et al. Longitudinal study of emotional experiences, grief and depressive symptoms in women and men after miscarriage. Midwifery 2018. 64. 23–28.

Bonding with the unborn fetus

Although it may be hard to believe, there was a time when pregnant mothers did not carry around an ultrasound image of their growing fetus. However, studies of the perceived reality of the pregnancy and the nature and intensity of grief following a miscarriage are extremely limited. It seems intuitively obvious that the more an individual had perceived the pregnancy and baby as “real” prior to the miscarriage, the more intense would be their level of grief, and this is indeed what has been found. However there have been contradictory studies with regard to the effect of viewing an ultrasound. One study of men who had viewed an ultrasound found that they had significantly more vivid images of their unborn child and higher levels of grief than male partners who had not seen an ultrasound. Another study found no difference, leading to the conclusion that “the effect of ultrasound on maternal attachment and the possible influence of ultrasound on bereavement reactions after perinatal loss await further systematic investigation.”

The Rules of Mourning and the Emotions of Mourning

Based on several passage in the Talmud, Maimonides ruled that there are no mourning rites after a miscarriage or for an infant that dies within thirty days of its birth. And this is codified in the Shulchan Aruch, the Code of Jewish Law (Yoreh Deah 374:8).

הלכות אבל א, ו

הַנְּפָלִים אֵין מִתְאַבְּלִין עֲלֵיהֶן. וְכָל שֶׁלֹּא שָׁהָה שְׁלֹשִׁים יוֹם בָּאָדָם הֲרֵי זֶה נֵפֶל. אֲפִלּוּ מֵת בְּיוֹם שְׁלֹשִׁים אֵין מִתְאַבְּלִין עָלָיו

We do not mourn for a fetus. Anything which does not live for thirty days is considered as a fetus.

The scholar Meir Bar Ilan has suggested that the infant mortality rate in Israel during period of the Talmud was around 30%. Given this, perhaps it made psychological sense to limit mourning rites for this most vulnerable of populations. Perhaps. Mercifully, things are different today, and there are new and creative rituals that might fill the vacuum left in traditional Jewish law. In 1996 the Conservative movement published a responsa titled Jewish Ritual Practice Following a Stillbirth, which noted that “contemporary rabbis and halakhic bodies cannot continue to treat a still-birth as non-event.” The same, surely, is true of a miscarriage.

In a few weeks we will learn the following Mishnah (Niddah 5:3, 44a):

תִּינוֹק בֶּן יוֹם אֶחָד… וַהֲרֵי הוּא לְאָבִיו וּלְאִמּוֹ וּלְכָל קְרוֹבָיו כְּחָתָן שָׁלֵם

a day-old infant…in relation to his father and to his mother and to all his relatives, is like a fully-fledged groom [whose death is deeply mourned].

This Mishnah is the record of another tradition, one which, with great care and sensitivity, understood that a miscarriage or neonatal death has meaning for a father and mother far greater than may be reflected in any legal decision.

“I gave birth to seven children, but I had a lot of miscarriages, maybe twice as many as my children, ... My first miscarriage, which was before I had children, was very hard for me. I awoke with shuddering pain. everyone was outside, and I cried hysterically. . . .

Afterward I learned that if a woman undergoes a miscarriage, it is actually a fetus that comes to repair something, and blessed be God. He chose a woman who observes the commandments, to keep the holiness of the soul. . . . That really encouraged me.”

— Engelsman S.P Huss E. Cwikel J. How Ultra-Orthodox (Haredi) Israeli Women Cope with Normative and Difficult Pregnancy and Childbirth Experiences. Nashim 2018. 33; 136-157