Thursday, August 20, 2009

Nishtaneh HaTeva (Nature Changed) And C-Sections

The Mishna in the eighth perek of Bechoros, Yesh Bechor L'Nachalah, discusses two children born, one via Cesarean section and the second afterwards via normal vaginal delivery. What is the status of each in terms of inheritance and in terms of redemption of the firstborn from a kohen.

In the following beautiful manuscript of Perush Hamishnayos of the Rambam, from JNUL, we have the Mishna and the Rambam's commentary:
Mishnah: A child born via Cesarean section, and the one who comes after him, neither of them is the firstborn, not to inheritance nor to the kohen. Rabbi Shimon says: The first one to inheritance and the second one to the five selaim {to redeem him from the kohen}.

Rambam: What is possible to be in this is that the woman was pregnant with two fetuses, and her belly was ripped open and one of them came out, and subsequently the second one came out in the normal way {, that is, vaginally}. But that which some relate, that the woman lives after they rip open her belly, and she becomes pregnant and then gives birth, I do not know of any grounds for it, and it is a very strange matter. And the halacha is not like Rabbi Shimon.
The reason they do not suggest that the man has two wives is that the redemption of the firstborn is based on the peter rechem of the woman, so there would be no question according to the Tanna Kamma that at the least, the second child would have a pidyon haben. Therefore it must be dealing with a case of one woman and two of her children.

The Rambam would seem to be right, in that in the ancient world Cesarean section was practiced on pregnant women who had already died; and if not, the extreme likelihood would be that the woman would die soon after. And if not, the operation could likely ruin her anatomy to an extent that she would not become pregnant again, or if so, bear a living child. Therefore, he came up with a clever case which works out with the medical reality of Rambam's time, but in all likelihood in Chazal's time as well. The woman was pregnant with twins, and so she would not have to live long to have the conceive and then bear the second child.

Though plausible, I am not certain this is necessary. Even if the case is farfetched or approaching impossible, it is remotely possible that Chazal were unfamiliar with the aftereffects of C-section. I don't find this likely. But it is also possible that they did not care about the odds or plausibility, and this is a hypothetical case constructed to get to the heart of the theory of the laws of pidyon haben and nachalah; such a constructed case allows us to see the opposition of the Tanna Kamma and Rabbi Shimon, and perhaps apply these theories of the law to other cases which do exist.

In a recent post on Hirhurim, Rabbi Ari Enkin discussed the topic of inducing childbirth in a fairly interesting manner. And in the course of that post, he mentioned a teshuva in Igros Moshe, Yoreh Deah, chelek 2, siman 74.

In the course of this teshuva, Rav Moshe Feinstein that many times nowadays the woman gives birth via C-section and subsequently, many times, gives birth in the normal way. He notes this Rambam in perush hamishnayos, which claims it is impossible. But nowadays, they perform the cut to remove the child via the wall, and the woman survives, becomes pregnant, and bears the child. And this happens thousands of times, and the doctors say that this is not such a danger.

Rabbi Feinstein's solution: perhaps nature changed from the time of the Rambam.

To this, we can say that of course (rather than "perhaps") something changed from the time of the Rambam, but it is not nature but rather medical knowledge and procedures. Here is a short history of the procedure.

By the time Rav Moshe was writing, they had already discovered the germ theory of disease, and could take precautions to avoid and treat infection. Meanwhile, in ancient times, or in the Rambam's time, they had developed medicine, some of which probably worked but much of it based on incorrect theories which could make such a procedure lethal.

Indeed, childbirth in general was much more dangerous back then, with many women dying in the process. Again, it is not so nowadays, but not because of nishtaneh hatava in terms of nature changing, but rather the medical knowledge and standards of medical care have vastly improved since then. I am not certain that such a revelation or position would have convinced him, but later in the same teshuva (the next paragraph) he asserts that leidah is never a real sakana to life, in accordance with a Divine promise, for how can we ask women to enter into this threat of death for peru urevu; and women only die during labor for the three sins mentioned in the gemara because they incurred punishment. But this Divine Promise would not be present when the woman moves up the time of labor, and it would therefore be forbidden to move it up.

This is an interesting interpretation of the gemara. I always understood the peshat to be that it is because one enters into an instance of sakana that he or she is judged. This seemed fairly clear from the context. Citing from my translation of the Rif's citation of the gemara:
And why specifically at the time of childbirth?
Rava said: When the ox is fallen, sharpen the knife. {that is, when they enter into a situation of danger, they are judged}

[And men {as opposed to women}, when are they inspected?
Rava {our girsa: Resh Lakish} said: At the time that they pass over a bridge.
Over a bridge, and other instances no?
Rather, that which is similar to a bridge.

Rabbi Yochanan said: A man should never walk into a place of danger and say that a miracle will be performed for him, lest a miracle is not performed for him, and if a miracle is performed for him, it detract from his merits.
It is admittedly always possible to interpret the gemara in other ways. But it is hard to square this idea that there would really be no sakana in the first place, because of some Divine Promise. Sickness and death following childbirth was exceptionally common, even when labor was at its proper time. Though it seems that Rav Moshe Feinstein was not denying this, but rather saying that the Divine Promise changed the typical order of the world. And one is forbidden to place oneself into sakana, which this is absent the Divine Promise. (Not positing Divine Protection in the general case, but rather invoking Diving Judgement in the particular case because the general case has sakana, which is an idea also found in Ramban's Shaar Hagmul, would not yield the same worldview and would not yield a prohibition, since the sakana is equal in every case, and the person's merits or demerits would be the same in every case.)

But these two different shades of nishtaneh hateva could still have repercussions. If medical practices have improved the odds for surviving a Cesarean section in modern times, then even if there is sakana in the general case of pregnancy, for the typical case it is much less of a sakana than it would be in ancient times. And doctors inducing labor do so after calculating the risks for the particular woman. And perhaps we should rely on their assessment, either that there is risk if they do not induce (something to which Rav Moshe agrees) or that there it is relatively safe even if they induce for other reasons. Maybe it was true sakana in the general case only in ancient times, but the nishtaneh hateva of improved medical knowledge and practice has more or less eliminated most of the sakana nowadays.

It seems he favors the former theory of nishtaneh hateva. In the next paragraph, he deals with the idea that if early induction were possible, why would they not require it in the time of Chazal in order to avoid Chillul Shabbos. He answers first that it would cause the child to be born prematurely, and we know of the famous nishtaneh hateva that children born in the eighth month would not survive back then, but they do nowadays. He does not answer that back then they were unaware of hormones and of oxytosin, which could be used to induce labor. (Of course, he leads the teshuva with uncertainty that such a process exists, and that the questioner did not mean to refer to a C-section.) But it is likely that they did not know of oxytosin back then, and thus could not reliably induce labor, and it is the medical knowledge and practice which had changed.

It might be safer, from a theological perspective, to say that nature has changed, rather than that our knowledge of nature has changed. But this cuts to the heart of two approaches to dealing with difficult passages in the gemara: do we say that Chazal's science was wrong, or incomplete, such that they would not know how to induce labor with oxytosin? or do we say that the very nature of reality changed since then, perhaps relaxing the radical aspect of such a statement by restricting it to things caused by environmental factors?


Menachem Mendel said...

Preuss in his Biblical and Talmudic Medicine says that there is no evidence of a Cesarian section on a live person who survived before the 16th c. He says that maybe it was a rare occurence and therefore discussed by the rabbis. Another possibility is that Yotzei Dofen means something else. His last suggestion is that the rabbis were speaking theoretically and that they never really saw a Cesarian section done on a live woman who survived.

yaak said...

The classic cases of Nishtaneh Hateva are:

ענינותא דוורדא
(חולין מז. תוס' ד"ה כל)

פרה בת שלשה שילדה
(mentioned in the same Tosafot and 2 other Tosafots in Bechorot 19b and A"Z 24b and Tiferet Yisrael to Bechorot 3:1)

יולדת למקוטעין
אה"ע סי' קנו ס"ד בהגה
and this one may be very relevant to your post.

Also, the Magen Avraham on סי' קעג ס"ב and on סי' קעט ס"ו

joshwaxman said...


and thanks. i'll try to check it out. back from your hiatus?

joshwaxman said...

the first magen avraham, btw, we were just discussing on the hirhurim thread.

Menachem Mendel said...

To emphasize the possibility of a yotzei dofen, or at least the mishnah quoted, being theoretical, does anyone think that all of the possibilities discussed in Yevamot really happened? Preuss emphasizes that there is not one example of a ma'aseh anywhere involving a woman having a cesarian section and living.

On the topic of hishtanut ha-tivi'im, I have a book by Nuria Gotel Sefer Histanut ha-Tivi'im be-Halakhah. This mishnah and the Rambam's perush is brought on p. 92.

yaak said...

Yes, I'm back.
I forgot to mention that there are a bunch of Hilchot Nidda ones that happened in the last century or so. Obviously, not in the classical sources.
I'm aware of the hirhurim discussion.

Michael said...

A few random thoughts,
The wikipedia article does seem to state that there were a few cases of c-section where the mother survived. They also implied that africans in the 19th century did c-sections, and the doctors learned from them that it is possible.
I do not no whether this kind of surgery was performed in ancient times. We now know that all kinds of surgeries were performed in ancient egypt and greece.
Maybe hishtana hateva means that women were more resilient to infection in the past.
We know that in the 19th century, birth mortality actually increased 10 times, due to doctors not washing hands before procedure(afer doing autopsies in the morgue). In rural communities the mortality was very low, because the midwives did sterilize, without understanding germ theory, just out of tradition.

joshwaxman said...

my guess is that there was no nishtaneh hateva between Chazal and Rambam regarding this, and so he is either correct in his farfetched scenario or, more likely, that it was a hypothetical. but even if there was, that is not what is imho most interesting.

what i find more interesting is the way in which rav moshe feinstein chooses to explain the nishtaneh hateva between the rambam's day and his own, where surely something changed...

shabbat shalom,

SPACE said...

Rav Feinstein discusses many interesting things in his book-responsa "Igrot Mosheh, Yoreh De'ah vol.3, 52. For example, in talmudic times, menstruation only ceased three months after conception, today menstruation almost always ceases immediately after conception. Also, in earlier era, a woman was considered "free of menstruation" for two years after birth. Today, menstruation usually resumes quickly after birth. There's many interesting things on topic "nature has changed"


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