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 in June 2019, when we study Arachin in the Daf Yomi cycle.

Maternal Death Rates

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, as an investigation from NPR last month detailed. Each year, 700-900 women die from pregnancy or childbirth-related causes, or about 14 per 100,000 live births. By comparison, the rate in Israel is 5 deaths per 100,000 live births.

From Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015, The Lancet. Only data for 1990, 2000 and 2015 was made available in the journal.

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.