Bava Basra 155b ~ Delayed Puberty in Boys

In today's page of Talmud we read about the treatment for the delayed onset of puberty:

כי אתו לקמיה דרבי חייא אי כחוש אמר להו זילו אבריוהו ואי בריא אמר להו זילו אכחשוהו דהני סימנין זמנין דנתרי מחמת כחישותא וזמנין דנתרי מחמת בריותא

Whenever people came to Rabbi Hiyya [with a case of a man who had not developed pubic hair]  he would tell them, if [the man was] thin, ‘Let him gain weight’; and if they were overweight he would say ‘Go lose weight’; for these signs [of sexual maturity] are sometimes delayed as a result of emaciation and sometimes  as a result of obesity.   (Yevamot 97a)

Rabbi Hiyya probably lived in the second half of the second century, and the treatment he suggested is one of the earliest examples associating nutritional status and delayed puberty.  Elsewhere in the Talmud we find this statement attributed to Rava, who died around 350 CE. But whoever suggested it first, I have found nothing in the works of Hippocrates, Aristotle and Galen that address this issue, so this association does not appear to have been a widely held belief in antiquity that was simply being echoed in the Talmud. 

There has been some discussion of what appears to be the increasingly earlier onset of puberty in girls. In fact, menarche, (the age of a girl's first menstrual period) has been steadily decreasing by a consistent three years per century of record keeping. However, R. Hiyya was addressing not the early onset of puberty in girls, but its delayed appearance in boys.  He noted that this delay was sometimes related to extremes of nutritional status, and so in these cases, was amenable to intervention.

“R.Hiyya may have been the first first to report an association of obesity and delayed puberty in boys.”

R.Hiyya was on to something. He (or Rava) may in fact have been the first to report an association between obesity and delayed puberty in boys.  This association has been confirmed by several studies which found that obesity has different effects on puberty in boys and girls. In girls, obesity is associated with earlier puberty, while in boys it has the opposite effect, and delays sexual maturation. But it was not until 2010 this association was confirmed by a longitudinal population-based study. This reported that a "higher BMI z score trajectory" (i.e. obesity)  during early to middle childhood may be associated with later onset of puberty among boys. 

The finding that puberty may be delayed in boys who are underweight has also been confirmed. As far as I can tell, none of the researchers has credited Rava (who died around 350 CE.) or Rabbi Hiyya for being the first to notice these associations. But they were first, and firsts count for something in science.

Bava Basra 142 ~ Maternal Deaths

Suetonius' Lives of the Twelve Caesars, 1506 woodcut.

Continuing the laws of inheritance, the Talmud rules that a fetus is not able to inherit from its mother until it is born. Then comes this technical question:  

למימרא דהוא מיית ברישא והא הוה עובדא ופרכס תלתא פרכוסי אמר מר בר רב אשי מידי דהוה אזנב הלטאה שמפרכסת

Does this mean that [when a pregnant womean dies,] the fetus always dies first [i.e. before its mother]? But there was a case where a pregnant woman died and after that the fetus thrashed around three times? Mar bar Rav Ashi said: That movement of the fetus does not indicate that it was alive. It was rather like the severed tail of a lizard, which thrashes about."

According to Mar bar Rav Ashi, the movement of a fetus inside its dead mother is not an indication of independent life. Instead it demonstrates reflex movements.  Here is one of those squirming detached lizard tails.

i saw this big lizard outside but it wasnt moving so my dad told me to poke it but it still wouldnt move so he threw mre a board i hit the lizard with it then it crawled at least a few inches then my dad told me to make its tail come off so i put the board on its tail then it crawled away and left it bloody tail beside and it started scwerming around enjoy!!

Mar bar Rav Ashi's explanation does not however, apply across all cases of the death of a pregnant woman. This is made clear by the Talmud in Arachin 7b:

Rabbi Nachman said in the name of Shmuel: A woman who sat on the birthstool and died on the Sabbath, we bring a knife and cut open her abdomen and remove the fetus.

This teaching clearly allows for the possibility that a fetus could survive the death of its mother. In fact the Talmud expands on the teaching of Mar bar Rav Ashi.  The observation that in cases of maternal death the fetus dies first seems to only be true in cases in which there is a "natural death." However, in cases in which a pregnant woman was executed, it is the mother who dies first, followed by the demise of the fetus:

ערכין ז, א

הני מילי לגבי מיתה איידי דוולד זוטרא חיותיה עיילא טיפה דמלאך המות ומחתך להו לסימנין אבל נהרגה היא מתה ברישא

This applies only to [her natural] death, because the child's life is very frail, the ‘drop’ [of poison] from the angel of death enters and destroys its vital organs, but in the case of death by execution she dies first.

Gruesome as this discussion is, the Talmud is likely correct. "Natural" maternal deaths that occur are likely from causes that will inevitably have led to the prior death of the fetus, like massive hemorrhage or sepsis.  In the case of execution, the sudden death of the mother would occur before that of the fetus. Thankfully, the execution of pregnant women no-longer occurs in our society, but a similar outcome can occur when the mother is a victim of severe traumatic injury.  We will return to this when we study Arachin in the Daf Yomi cycle.

Maternal Death Rates

“Between 2000 and 2020, eight countries recorded substantial increases in MMRs: Venezuela (182·8%), Cyprus (107%), Greece (101·1%), the USA (77·9%),
Mauritius (62·1%), Puerto Rico (55·9%), Belize (51·3%), and the Dominican Republic (36·0%;)”

— Khalil, Asma et al. A call to action: the global failure to effectively tackle maternal mortality rates. The Lancet Global Health 2023: 11(8), e1165 - e1167

The Commonwealth Fund. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries. November 2020.

Maternal deaths are defined as by the World Health Organization as the death of a woman whilst pregnant or within 42 days of delivery or termination of pregnancy, from any cause related to, or aggravated by pregnancy or its management, but excluding deaths from incidental or accidental causes. Worldwide, there are at least 287,000 such deaths each year. A recent study of maternal deaths in 115 countries noted that there are three main causes: Bleeding, high blood pressure (leading to complications like eclampsia) and infection.  Here in the US, maternal deaths are among the highest in the developed world. Each year, 700-900 women die from pregnancy or childbirth-related causes, or about 17 per 100,000 live births. By comparison, the rate in Israel is fewer than 3 deaths per 100,000 live births - the third lowest of all OECD countries.

Maternal mortality rate estimates for the period 2010–20 Figures created with data from the UNICEF Data Warehouse.2 (A) MMR estimates for Brazil and the eight countries and territories that recorded substantial increases in MMR between 2000 and 2020. (B) MMR estimates for the three countries (all in sub-Saharan Africa) where MMRs in 2020 surpassed 1000 maternal deaths per 100000 livebirths. (C) MMR estimates for the three countries that recorded over 10000 maternal deaths each in 2020. MMR=maternal mortality ratio. From Khalil, Asma et al. A call to action: the global failure to effectively tackle maternal mortality rates. The Lancet Global Health 2023: 11(8), e1165 - e1167

Tragic as each of these deaths are, it was once a lot worse, and in the nineteenth century doctors played a major role in causing maternal deaths.  In Vienna, Dr. Ignaz Semmelweiss (d. 1865) noted that the death rates in one maternity ward were three or four times higher than in a second ward. He suggested, after much sleuthing, that the cause was the dirty hands of medical students. These students came straight from performing autopsies to examining their pregnant and post-partum patients, with no hand washing in between. In an era before the germ theory of disease, his suggestion that something was carried on the hands of the medical students was widely ignored, but he instituted compulsory hand-washing anyway. And within a year the death rate dropped to zero.

Over the past century the maternal death rate in the US has declined by over 99%, although there are still significant racial and economic disparities. Passages such as the one we read in today's Daf Yomi remind us that for centuries, giving birth was a dangerous experience.  

Help Talmudology Climb Kilimanjaro!

The very first Talmudology post was published on November 14, 2014. That’s almost exactly a decade ago. It has been an absolute joy to undertake this project, and I want to thank each of you for being loyal readers.

Talmudology was never about making money. It was about thinking about Jewish texts together with you. But now, I am asking for something other than your time to read a post. I want your money.

Well, to be precise, I don’t want your money. Shalva does. Shalva, whose headquarters are in Jerusalem, provides an all-encompassing range of services for thousands of people with disabilities from infancy to adulthood, together with their families. Its comprehensive life-cycle programming provide leading-edge therapies, inclusive educational frameworks, social and recreational activities, employment training, and independent living, as well as respite and family support. The list goes on and on, and it does all this regardless of religion, ethnic background, or financial capability. Since the beginning of this terrible war, it has taken on additional responsibilities in providing respite care. Because that’s what they do.

As a fundraiser, Shalva has organized a kosher, shomer shabbat climb of Kilimanjaro. It was supposed to leave last January, but was postponed after the war broke out. Talmudology will take part, and there will be a special surprise at the peak.

KILIMANJARO FAQs

When is the trip?

It leaves on Sunday, January 19, 2025, and returns on Thursday January 30th. The full timetable is here.

How many people will be climbing for Shalva?

Currently there are about twenty-two registered climbers.

I like the idea of supporting Shalva, but I don’t want to spend my charity so that someone can mess around on a mountain for ten days.

I agree. That’s why every penny of your sponsorship will go to Shalva. I have already covered the airfare, permits, food, and the support team. So whatever amount you sponsor, none of it will be used to cover the costs of the trip itself. So go ahead, sponsor!

What is the success rate of reaching the summit?

Overall, the success rate is 60-80% across all tour operators. But it varies by route. The quicker the route, the lower the success rate. I will be climbing the slower eight-day Lemosho route, and it includes a Shabbat at rest. It has a success rate of 90-95%. (The route. Not Shabbat).

Um, asking for a friend: How many people die trying to climb Kilimanjaro?

Because the Kilimanjaro National Park authorities do not release these statistics, it is not possible to know just how many fatalities occur. Each year there are about 30,000-50,000 climbers, and about 10 fatalities, or about 0.02%. So, nothing to worry about.

What’s the surprise at the peak?

Summit day is Tuesday January 28th, and on that day, daf yomi will be learning Sanhedrin 42. Talmudology plans to give the World’s Highest Daf Yomi Shiur that day, at an incredible 19,341 feet (5,904 m). We will spend Shabbat at 12,795 feet (3,900m) so it won’t be the world’s highest Shabbat; that seems to have been celebrated at 15,540 feet (4,730m) on Mount Everest. But it will, to the best of our knowledge, be the highest daf yomi shiur ever given. And with your help, we can set that record.

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Bava Basra 126b ~ The Healing Power of Saliva

In a chapter that deals with the rules of inheritance, there is this interesting aside:

בבא בתרא קכו, ב

 ההוא דאתא לקמיה דרבי חנינא אמר ליה מוחזקני בזה שהוא בכור אמר ליה מנא ידעת אמר ליה דכי הוו אתו לגבי אבוה אמר להו זילו לגבי שכחת ברי דבוכרא הוא ומסי רוקיה ודלמא בוכרא דאמא הוא גמירי בוכרא דאבא מסי רוקיה בוכרא דאמא לא מסי רוקיה

A certain person once came before R. Hanina and said to him, 'I am sure that this man is firstborn'.  R. Hanina said to him, 'How do you know?' — The person replied to him: 'Because when people came to his father,  he used to say to them: "Go to my son Shikhath, who is firstborn and his saliva heals'. Might he not have been the firstborn of his mother only [but not of his father]? There is a tradition that the saliva of the firstborn of a father heals, but that of the firstborn of a mother does not heal.

Being declared a firstborn son was a big deal in talmudic times, for that lucky son would inherit twice the share of any other brothers.  (Daughters only inherit where there are no sons, or offspring of sons.) In the case brought before R. Hanina, there were two claims. One, that the Shikhath was a firstborn, based on the fact that his father called him "firstborn", and second that he was his father's firstborn by any woman. The evidence for that is the claim that his saliva heals. In talmudic society, only the saliva of a firstborn of a father heals. In his commentary on this passage, the Rashbam adds that the healing properties of saliva refer to its use as an eye medication. What are we to make of these claims that saliva heals, but only if it is the saliva of a firstborn son?

The many functions of human saliva

Saliva is an amazing material, and one we too often take for granted.  The many functions of saliva were reviewed in a paper published in The Archives of Oral Biology in 2015. We make a lot of it - about half a liter per day - and we need it to moisten and lubricate our mouths. It plays a critical role in taste, since it helps dissolve the foods into components that transmit taste on the tongue.  Saliva is also a key component of digestion. One of its main components is alpha-amylase, which appears to have a role in the breakdown of starch. It also protects the oral mucosa and esophagus not only by acting as a lubricant, but by buffering the acids in the stomach that sometimes make their way north into our mouths. The dentists among you will already know that saliva protects the teeth against abrasion, attrition, erosion, and dental caries, by removing uneaten food debris from the mouth. This debris, especially if sugary or acidic, can damage our teeth when bacteria feed off them. Saliva also has activity against bacteria, viruses and fungi.  For example, submandibular saliva inhibits the HIV-1 virus, even when diluted several-fold, and saliva inhibits the growth of candida, an opportunistic oral fungus.   

Saliva and wound healing

Last year, scientists from Lahore in Pakistan tested the ability of human saliva to heal wounds. They collected saliva from 24 willing human spitters, and applied the saliva to 2cm x 2cm wounds on the backs of  thirty "fully grown adult male rabbits weighing 2.0 to 3.4kg..." Three rabbits were controls and received no treatment. Another three had standard antibiotic ointment applied to their wounds, and the remaining lucky 24 rabbits had saliva applied every two hours for two weeks.  The Pakistani scientists noted "the healing speed of wounds on which saliva was applied was higher than the wounds on which wound healing medication (polyfax) was applied, and there was pus formation in the wound of negative control on which natural healing was observed." They concluded that "healthy human saliva possess significant (p<0.05) antimicrobial as well as wound healing properties. This innate ability of human saliva, mainly attributed to histatin protein, suggests that salivary proteins can be further used for medicinal purposes."

Wound healing properties of saliva, polyfax, and control on induced wounds on the backs of rabbits. From Haq et al.  Antimicrobial and Wound Healing Properties of Human Saliva. Int. J. of Pharm. Life Sci. 2016. 7 (2); 4911-4917.

“Healthy human saliva possess significant antimicrobial as well as wound healing properties. This innate ability of human saliva, ... suggests that salivary proteins can be further used for medicinal purposes.””

— ul-Haq, F et al. Antimicrobial and Wound Healing Properties of Human Saliva. International Journal of Pharmacy and Life Sciences. 2016:4911-4917

The histatins to which the Pakistani researchers referred are a group of proteins in the saliva which in 2008 were found to promote wound healing.  Cuts in the mouth heal much more quickly than do cuts elsewhere on the body: researchers have found that "wounds in the oral cavity heal much faster than skin lesions, with similar wounds healing in 7 days in the oral cavity compared with several weeks on the skin," and this is thought to be due to these histatins in the saliva.  

The mouth is a very dirty place

A nasty fight-bite injury, due to bacteria found in the mouth.

All this sounds rather interesting and would seem to support the use of saliva to heal, just as the saliva of Shikhath was said to do in today's page of Talmud. If however you find yourself with a wound and no local pharmacy, you might want to consider this before licking yourself.  The mouth is a terribly dirty place, microbiologically speaking.  It is full of nasty bacteria viruses and fungi, which the saliva only just manages to keep at bay.  I have seen dozens of  "fight-bites" in the ED. They are the outcome of a fist hitting a tooth (usually late on a Saturday night) and the hand often becomes badly infected as the bacteria in the victim's mouth, now safely hidden away deep in the crevice of the wound on the assailant's knuckle, go to work.  The result isn't pretty.

Vespasian, and others who healed with their saliva

The belief that saliva can heal the eyes is not limited to today's page of Talmud. You can find a detailed history in the 1891 paper by Frank Nicolson, The Saliva Superstition in Classical Literature. Perhaps one of the most striking examples of saliva as an ophthalmic medication is from the works of Tacitus, a Roman senator and historian, who died around 120 CE.  In his Histories, he recounts the story of Vespasian, - the same Vespasian who fought the Jewish insurrection in Judea and whose son Titus destroyed the Second Temple in 70 CE.  

In the months during which Vespasian was waiting at Alexandria for the periodical return of the summer gales and settled weather at sea, many wonders occurred which seemed to point him out as the object of the favor of heaven and of the partiality of the Gods. One of the common people of Alexandria, well known for his blindness, threw himself at the Emperor's knees, and implored him with groans to heal his infirmity...He begged Vespasian that he would deign to moisten his cheeks and eye-balls with his spittle... Vespasian, supposing that all things were possible to his good fortune, and that nothing was any longer past belief, with a joyful countenance, amid the intense expectation of the multitude of bystanders, accomplished what was required...the light of day again shone upon the blind. Persons actually present attest [this fact], even now when nothing is to be gained by falsehood.

(In case you were wondering, Vespasian was not a firstborn, but the third child born to his parents.)

Jesus is also said to have healed the blind with his saliva, as told in Mark 8:23-25:

They came to Bethsaida, and some people brought a blind man and begged Jesus to touch him. He took the blind man by the hand and led him outside the village. When he had spit on the man’s eyes and put his hands on him, Jesus asked, “Do you see anything?” He looked up and said, “I see people; they look like trees walking around.” Once more Jesus put his hands on the man’s eyes. Then his eyes were opened, his sight was restored, and he saw everything clearly.

This sort of thing carried on in a slightly different version through the Middle Ages. It involved not spittle, but touch. Here is Jack Hartnell, a lecturer in art history at the University of East Anglia in Norwich in the UK describing the healing power of kings in his 2018 book Medieval Bodies (p199).

[B]y the later Middle Ages. the touch of a monarch themselves, especially immediately after such coronation rites, had reciprocally been transformed into a much-prized thing. So charismatic was this touch that in certain cases it was even thought to have the ability to heal various illnesses through royal caress. Srofula, a form of tuberculosis of the lymph glands causing large sores and swellings around the neck, was a disease that became so associated with this type of monarchial healing that it took the Latin name morbus regius, the ‘regal disease’ or, sometimes, the ‘king’s evil.’ From the eleventh century onwards its French and English victims were granted special audiences with their respective monarchs to receive this miraculous cure. Records are hazy as to how precisely such healing touches were given: some royals may have employed a lingering stroke of the face and neck, while others may have had to do with a simple pat on the head. Either way, the hands of the king carried immense power.

In sum, the belief that saliva could heal the eyes and cure the blind was not only found in Jewish culture, but was part of Roman and early Christian legend. We now know that purified saliva does contain proteins and growth factors with anti-microbial and wound healing properties. However, the notion that saliva taken from the mouth might be helpful for failing eyesight is entirely without scientific foundation, because you are more likely to introduce an infection than you are to cure one. Even if you are a firstborn, an emperor, or a messiah.