Long-Term Consequences of Castration in Men: Lessons from the Skoptzy and the Eunuchs of the Chinese and Ottoman Courts
Jean D. Wilson and
Claus Roehrborn
Departments of Internal Medicine and Urology, University of Texas
Southwestern Medical Center, Dallas, Texas 75235-8857
Address all correspondence and requests for reprints to: Dr. Jean D. Wilson, Departments of Internal Medicine and Urology, 5323 Harry Hines Boulevard, University of Texas Southwestern Medical Center, Dallas, Texas 75235-8857.
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Introduction
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Castration of men and males of other species was
almost certainly the first experiment in endocrinology (if not in
zoology), and the literature on the subject is vast. Indeed, the
Cumming Manuscript Collection of the New York Academy of Medicine
Library contains more than 1200 references, abstracts, and documents
concerning the early history of human castration (1). In antiquity the
procedure was performed for several reasons, including as punishment
for prisoners of war (2), and by the time of Aristotle in the fourth
century BC the physiological consequences of male castration were
understood with remarkable exactitude (3). "Some animals change their
form and character, not only at certain ages and at certain seasons,
but in consequence of being castrated; and all animals possessed of
testicles may be submitted to this operation. Birds have their
testicles inside, and oviparous quadrupeds close to the loins; and of
viviparous animals that walk some have them inside, and most have them
outside, but all have them at the lower end of the belly. Birds are
castrated at the rump at the part where the two sexes unite in
copulation. If you burn this twice or thrice with hot irons, then, if
the bird be full-grown, his crest grows sallow, he ceases to crow, and
forgoes sexual activity; but if you castrate the bird when young, none
of these male attributes or propensities will come to him as he grows
up. The case is the same with men; if you mutilate them in boyhood, the
later-growing hair never comes, and the voice never changes but remains
high-pitched; if they be mutilated in early manhood, the later growth
of hair quit them except the growth on the groin, and that diminishes,
but does not entirely depart. The congenital growth of hair never falls
out, for a eunuch never goes bald. In the case of all castrated or
mutilated male quadrupeds the voice changes to the feminine voice...
All animals, if operated on when they are young, become bigger and
better looking than their unmutilated fellows; if they be mutilated
when full-grown, they do not take on any increase of size. If stags be
mutilated when, by reason of their age, they have as yet no horns, they
never grow horns at all; if they be mutilated when they have horns, the
horns remain unchanged in size, and the animal does not lose them...
As a general rule, mutilated animals grow to a greater length than the
unmutilated (3)."
In contrast to the rapidity and sophistication of the early advances,
studies of the physiological effects of castration in more recent times
have been relatively limited (presumably because fewer castrated men
are available for study), and most studies of androgen deficiency focus
on hypogonadal states rather than castration (4). However, in the
1940s, Hamilton and his colleagues did pioneering work in the United
States on mentally deficient men who were castrated as a consequence of
eugenics laws, quantifying the effects on skeletal development,
hemoglobin production, and metabolism (5), and Bremer subsequently
defined the relation between testicular secretions and male sexual
drive and function in men who were castrated in Norway because of
sexual offenses (6). Most studies of castration in men have involved
relatively short term experiences (usually men who had been castrated
for less than a decade), but in the 20th century the effects of long
term castration have been studied in three groups of men: the Skoptzy
and the court eunuchs of the Chinese and Ottoman empires (Table 1
). According to Penzer (7) three
varieties of eunuchs were recognized in antiquity: 1) castrati,
clean-cut, both penis and testicles were removed; 2) spadones,
testicles only were removed; and 3) thlibiae, testicles were bruised
and/or crushed. The three groups of eunuchs under consideration in this
review fall into the castrati category.
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The Skoptzy
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The Skoptzy (or Skoptsy, meaning the castrated), also called the
White Doves, were a Christian sect whose male members, to attain their
ideal of sanctity, subjected themselves to castration. Their origin in
the 18th century, their spread through a large part of Russia and into
Romania and Bessarabia, the attempts by the Russian government to
suppress the movement, and the theological underpinnings of the
religion were described by Pelikan (8), Grass (9), and Pittard (10).
Because they believed that the second coming of Christ would occur only
when the number of Skoptzys reached the apocalyptic number of 144,000,
they became ardent proselytizers. Their critics claimed that they used
coercion among children and prisoners, a charge that seems warranted in
view of the fact that many were castrated below the age of 10 yr, but
others were religious enthusiasts who underwent the procedure
voluntarily as adults. Male members of the sect were encouraged to take
either the "great seal" (removal of the penis, the scrotum, and the
testes) or the "lesser seal" (removal of the scrotum and testes,
leaving the penis intact). Women were not castrated, but were subjected
to mutilation of the breasts and external genitalia. In men the
procedure was of great simplicity; namely, the operator seized the
parts to be removed with one hand and struck them off with the other.
In the early years of the sect the surgical instrument was a red-hot
iron rod or poker (hence the expression baptism of fire), but
instruments of castration included pieces of glass, razors, and knives.
A cicatrix formed, with healing in 46 weeks (Fig. 1
). In some instances the procedure was
performed in stages (taking the lesser seal before the great seal).
When the penis was removed, nails were inserted into the urethra to
avoid strictures, and such men were said to urinate while sitting or
squatting. Many Skoptzys were deported to Siberia, where they formed
settlements, and the sect continued to perform castrations as late as
1927 (11). Persecution of the Skoptzys persisted into the Soviet era,
and during the antireligious fervor in 19291930 they were subjected
to sensational public trials and publicity. It was estimated that there
were between 1000 and 2000 Skoptzy in Soviet Russia in 1930, 500 of
whom lived in Moscow, but by 1962 none were thought to be alive
(11).

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Figure 1. Anatomical preparation of the external
genitalia of a Skoptzy man who had received the greater seal. Reprinted
from Koch (13 ).
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Medical studies on the Skoptzy. Medical studies were performed
on the Skoptzy by at least three different groups of investigators. At
the turn of the century Pittard made measurements in 30 Skoptzy men in
1 Romanian village and noted that they appeared to be taller than their
peers (10). In 1907 Tandler and Grosz examined 5 Skoptzy men in
Bucharest whose average age was 30 yr and who had been castrated
between ages 521 yr (12). Subsequently, during the German occupation
of Romania in the First World War Walter Koch studied 13 Skoptzy men,
all between 50 and 94 yr of age (averaging 64 yr), who had been
castrated for an average of 46 yr (13). A variety of anthropomorphic
measurements were made, and skull x-rays were obtained in some
(13).
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The eunuchs of the Chinese court
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The practice of employing eunuchs as court functionaries in China
and in other oriental countries goes back into prehistory (14). The
procedure by which the Chinese court eunuchs were castrated in the late
19th century during the Qing dynasty was described in some detail by
Stent in 1878 (15), and subsequent descriptions of the practice,
including those by Korasow (16), Matignon (17), and Wong and Wu (18),
appear to be paraphrases of Stent (15). However, on the basis of
published interviews of surviving eunuchs, the surgical procedure
appears to have been essentially the same in the later days of the
dynasty (14). Possession and employment of eunuchs as servants in China
were reserved for the imperial family and the 8 hereditary princes. The
emperor maintained approximately 2000 in his service, the imperial
princes and princesses each had about 30, and various family members
were allowed 10 or so eunuchs each. On occasion, the castration was
punitive, as in prisoners of war, but most were performed voluntarily
in adults who, because of poverty or laziness, underwent castration to
gain employment (usually as young adults, but sometimes in men after
having born children) or in children under compulsion who were sold by
their parents for the purpose of castration (15).
Specialists (termed knifers) performed the operation in an
establishment maintained outside one of the palace gates in the
imperial city, and the trade was handed down from father to son. The
subject reclined on a broad bench, and the genitalia were anaesthetized
with a secret agent known only to the surgeon. Two assistants held the
spread legs, and a third assistant secured the arms. The surgeon stood
between the legs armed with a curved knife (Fig. 2a
), grasped the scrotum and penis with
his left hand, and asked the candidate or his parents to consent to the
procedure. If the answer was yes, the genitalia (scrotum, penis, and
testes) were removed with a single cut. A plug made of pewter (Fig. 2b
)
was introduced into the urethra to prevent stricture formation. The
wound was washed three times with a solution of boiled pepper and
covered with a piece of soft, moistened paper. With the support of two
assistants the subject was made to walk around the room for 23 h. For
the following 3 days, the subject was not allowed to drink liquids or
to urinate. On the fourth day, the dressing and plug were removed, and
if the subject was able to urinate the operation was considered a
success. Healing took approximately 100 days, and eventually all that
was left was a contracted scar (Fig. 3
).
Urinary retention was treated with drugs, and if it persisted the
surgeon beat the patient on each visit. Complications included
hemorrhage, infection, and extravasation of urine, but death was rare
(estimated at around 2%). Until convalescence was completed the pewter
plug was only removed to allow urination. With time the opening of the
urethra could become narrowed despite the use of dilators, resulting in
urinary dribbling or retention, urinary tract infection, and bladder
stones. Urinary incontinence was said to be common and caused a
characteristic odor in the unfortunate victims. The stoma sometimes
required dilatation long after the castration (16, 17, 18). [According to
Wagenseil, other castration techniques were sometimes used, each
involving the removal of all the external genitalia (19).]

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Figure 2. Some of the instruments used for creating
and treating eunuchs. a, Scalpel used by knifers for the removal of the
external genitalia of the Chinese eunuchs (the blade is described as
3.7 in. in length, and the handle as 2 in. in length.) Redrawn from
Wong and Wu (18 ). b, A urethral dilator for insertion into the urethra
of the Chinese eunuchs (3 cm long and 0.9 cm in the widest portion of
the plug). Redrawn from Matignon (17 ). c, A urethral plug used to
prevent incontinence in the Ottoman Court eunuchs (5 cm long). A string
was placed in the eye to prevent it from slipping into the bladder.
Redrawn from Millant (31 ).
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The amputated penis, testes, and scrotum, termed "the precious" or
"the treasures," were preserved in alcohol and either stored by the
knifer or kept by the subject (15, 16). Genitalia retained by the
knifers were kept in jars labeled to indicate from whom they came and
when the amputation was performed. The eunuchs were required to show
the preserved genitalia to a special court official at each promotion
("inspection of the precious") to document the completeness of the
operation, and eunuchs who, through carelessness or misadventure, lost
the items had to borrow or rent them for display at the time of
promotion. Each eunuch was buried with the preserved genitalia, because
of the religious need to be as complete as possible when departing into
another world.
The palace eunuchs were divided into 48 departments (for looking after
gardens, courtyards, kitchens, armory, furniture, etc.) Each
department had a superintendent, usually of the sixth grade, and a
chief eunuch served over the entire complement of eunuchs. At least in
the last phase of the Qing dynasty, eunuchs were subject to the
Imperial Household Department, which was not headed by a eunuch (20).
Most Chinese eunuchs were castrated as adults, but eunuchs castrated
before the age of 10 yr were considered thoroughly pure and were
prized as personal servants. All eunuchs received a regular stipend as
well as room and board. Most lived in the palaces until they were
released from service in old age. Some spent their final days in
monasteries. Those who had families and children before castration
rejoined their families, and others married and adopted children. The
most frequent marriage partners were palace maids; such wives were
referred to as companions sitting at meals to indicate a platonic
relationship (21). [George Kates, an American, rented a house in the
Imperial City in Beijing from one such couple in the 1930s, the wife
having been a maid to the dowager empress (22). This couple survived
until the Cultural Revolution of 196676, the wife dying of
malnutrition, and the husband disappearing after being deported to the
countryside (23).]
After the revolution of 1911 the emperor Pu Yi retained figurehead
status and continued to reside in the Forbidden City. According to the
articles of agreement with the new government, the existing eunuchs
continued to be employed in the Imperial Household Department (20).
However, on July 15, 1923, the entire staff of eunuchs (with the
exception of about 50 household servants of elderly members of the
imperial family) was expelled from the Forbidden City because they were
suspected of stealing and selling furniture and works of art and were
believed to have burned a portion of the edifice as a protest against a
planned inventory of the palace treasures (20). Although there is
disagreement as to whether the eunuchs were responsible (14, 20),
corruption in the Imperial Household Department was pervasive.
Medical studies on the Chinese court eunuchs. The expulsion of
the eunuchs from the Forbidden City left most unemployed and many
destitute. Ferdinand Wagenseil, from the Institute of Anatomy at
Freiburg but then at Tungchi University in Shanghai, conducted
anthropometric studies on normal men from northern China (24), and in
1930 he examined 31 eunuchs at the German Hospital in Beijing (19). The
technique of study involved measurements of height, weight, and a
variety of skeletal dimensions, radiographic studies of the skull, and
descriptions of skin and body hair. The average age in this group was
57 yr, and the average duration of castration was 38 yr. In 1960 Wu and
Gu (25, 26) performed careful physical examinations, including
palpation of the prostate in 26 eunuchs (5 of whom had been castrated
after the revolution of 1911) who lived in Beijing. The average age in
the latter study was 72 yr, and the average duration of castration was
54 yr.
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The eunuchs of the Ottoman court
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The practice of employing eunuchs as palace functionaries in
Constantinople (Istanbul) apparently began during the reign of the
Emperor Justinian in the latter days of the Roman Empire and persisted
through the Byzantine (27) and Ottoman eras (7). In contrast to China,
ownership of eunuchs in Turkey was not limited to the royal palaces;
any citizen who could afford the purchase price was entitled. Some
eunuchs of the Ottoman Empire were from Russia or the Balkans, but from
the 16th century black eunuchs were in charge of the harem in the
Ottoman court, most commonly individuals from Ethiopia or Sudan who had
been castrated as children (28). Slave dealers kidnapped some, and some
were sold into slavery by their parents. According to Penzer, stopping
points were used by the slave exporters, and it was during the halts at
such places that the castration of the boys took place (7). According
to other reports many of the boys were castrated at a monastery in
Upper Egypt where Coptic priests performed the operation (29, 30). The
child was restrained on a chair; the phallus and scrotum were tied with
a cord which was pulled taught, and the phallus, scrotum, and testes
were removed as close as possible with a single stroke of a razor.
Bleeding was stopped with boiling oil, and the wound was dressed with
an extract of wax and tallow. In some instances hemostasis was achieved
with hot sand, and the wound was dressed with an extract of acacia
bark. The mortality was said to be high, only about one in three
surviving. As in the case of the Skoptzy and the Chinese court eunuchs,
a nail was introduced into the urethra to prevent stricture formation.
The eunuchs squatted to urinate, and both urethral strictures and
incontinence must have been common, because some eunuchs carried silver
quills for self-catheterization, presumably because of strictures (7),
and others used a removable plug (Fig. 2c
) to prevent incontinence
(31). Owing to the high death rate, the survivors were sold at high
prices either to Turkey or to Persia (29). The physicians to the harem
inspected the eunuchs on arrival to be certain that both penis
and testes had been removed and reexamined them every few years
to be certain that nothing was amiss (7). The eunuchs entered the court
service at the lowest rank and passed successively through the grades
of novice, middle grade, and highest rank. Strict rules of behavior
were enforced for the eunuchs guild. Some took to learning and
literature and served as tutors to the royal children; others rose to
high administrative ranks (28). Some 200 eunuchs were said to have
lived in the palace of Topkapi in Istanbul after the royal family had
moved to other palaces (28), and after the Turkish revolution the
eunuchs continued to be devoted servants until the royal family was
sent into exile in March of 1924 (32).
Medical studies on the Ottoman court eunuchs. Hikmet and
Regnault appear to have made the first medical observations on the
eunuchs in Istanbul in 1901 (30). During the first world war Ferdinand
Wagenseil had been assigned as a physician to the German Red Cross
Hospital in Istanbul, where he took care of a 40-yr-old eunuch from the
harem who died after a febrile illness (presumably typhus) and
subsequently examined 10 additional eunuchs, most of whom had voiding
difficulties (33). An autopsy was performed on the man who died; the
others (average age, 43 yr; average duration of castration, 34 yr) were
subjected to detailed anthropological measurements and physical
examinations, and skull x-rays were obtained on four of them.
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The medical consequences of long term castration
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Because the findings in the various studies overlap and are
complementary, they will be discussed together.
Enlargement of the pituitary. Tandler and Grosz obtained an
x-ray of the skull in a 20-yr-old Skoptzy man, who had been castrated
at age 10 yr and observed that the sella turcica was grossly enlarged
(12). Koch obtained x-rays of the skull in 10 Skoptzy men and reported
that the pituitary glands were normal in size in 3, enlarged in 4, and
"particularly" enlarged in 3 (13). In the latter group, there was
also erosion of the dorsum sellae of the pituitary ("sattellehne").
The average duration of castration was the same in the 3 groups studied
by Koch (46 yr), but the average age at which the castration was
performed (11 yr) was younger in the group with the largest
pituitaries. In his Istanbul study Wagenseil reported that 2 of 4 skull
x-rays obtained revealed enlargement of the pituitary with thinning of
the dorsum sella; the average age at castration was 11 yr, and the
average duration of castration was 44 yr in these 2 men (33). In the
same study the pituitary was normal at autopsy in the 40-yr-old man who
had been castrated for an uncertain duration (33). In his Beijing study
Wagenseil obtained skull x-rays on 27 eunuchs and had them reviewed at
the University of Bonn where "enlargement of the sella turcica could
not be found generally" (19). The reason for the apparent discrepancy
between the findings in the Chinese eunuchs and those in the Skoptzy
and the Ottoman eunuchs is not clear, but it is of interest that the
average age at which castration was performed was older in the Chinese
group (average age at castration, 18 yr; less than a fourth had been
castrated before age 14 yr). Subsequently, reactive hyperplasia of the
pituitary was described in hypogonadal men (34, 35, 36), including men with
Klinefelters syndrome (37). There is in addition at least one
instance in which a large gonadotropin-secreting pituitary adenoma
developed 35 yr after a man was castrated for cryptorchidism (38).
Skeletal changes. Tandler and Grosz described failure of
closure of the epiphyses in the skeleton of a eunuch (39) and
subsequently in a 35-yr-old Ottoman eunuch who had been castrated at
age 8 yr (12) Koch reported that thinning of the bones of the skull was
evident by x-ray in all of the Skoptzy men examined and that kyphosis
was common (Fig. 4
) (13). Likewise,
Wagenseil observed that 20 of the 31 Chinese eunuchs had kyphosis of
the spine (Fig. 5
) (18). These
observations appear to have been made before it was recognized that
kyphosis is a manifestation of severe osteoporosis in women (40). In
the Wagenseil study, men with kyphosis averaged 59 yr of age and had an
average duration of castration of 42 yr, whereas the men who did not
have kyphosis were slightly younger (average age, 54 yr) and had a
slightly somewhat shorter average duration of castration (33 yr) (18).
Involvement of the spine is common in men with osteoporosis of various
etiologies (41), and in view of the fact that bone mineral density
decreases progressively with time after castration, particularly in the
first few years (42), it is surprising that kyphosis was not even more
common in the Chinese eunuchs and the Skoptzy. Furthermore, an
increased incidence of fractures does not appear to have been reported
in the eunuchs, and Wagenseil had not observed kyphosis in his earlier
study of eunuchs in Istanbul (33). The reason for the discrepancy
between the Turkish study and the other studies is not clear. The
Turkish eunuchs were somewhat younger (average age, 44 yr), and were
either Ethiopian or Sudanese in origin and might have had higher
initial bone densities (43). Alternatively, osteomalacia due to vitamin
D deficiency was common in Northern China in the early years of this
century (44), and vitamin D deficiency might have contributed to
osteopenia in the Chinese eunuchs (and possibly in the Skoptzy).

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Figure 4. Photograph demonstrating kyphosis in a
54-yr-old Skoptzy man who had been castrated at age 15 yr. Reprinted
from Koch (13 ).
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Figure 5. Photograph demonstrating kyphosis and
gynecomastia in eight Chinese eunuchs. The average age of these men was
56 yr, and the average time lapsed since castration was 38 yr.
Reprinted from Wagenseil (19 ).
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Gynecomastia. Hikmet and Regnault reported that the breasts in
the Ottoman court eunuchs became large and pendulous (30) Although not
commented on by either author, gynecomastia is also evident in 5 of 9
photographs of Skoptzy men published by Koch (13) and in 7 of 14
photographs of Chinese eunuchs published by Wagenseil (19) (Fig. 5
).
Furthermore, Wu and Gu reported that 9 of the 26 subjects in their
study had breast enlargement (25, 26). These observations of
gynecomastia in castrated men are in keeping with the subsequent report
by Heller, Nelson, and Roth that approximately half of men with
functional prepubertal hypogonadism develop gynecomastia (45). In
hypogonadal men, gynecomastia develops when estrogen formed by
extraglandular aromatization of adrenal androgens is sufficient to
cause breast enlargement in the face of profoundly low testosterone
values (46). The reason that gynecomastia develops in some but not all
men with primary hypogonadism is not known.
Apparent disappearance of the prostate. Androgen action is
required for the development of the prostate gland during embryogenesis
(47), and the prostate does not develop in men with mutations that
profoundly impair the function of the androgen receptor (48) or
of steroid 5
-reductase-2 (49). Furthermore, it has been known since
the 19th century that prostatic hyperplasia does not develop in
prepubertal castrates and that castration causes regression of the
hyperplastic prostate (50). Hikmet and Regnault reported that the
prostate became atrophic in the Ottoman court eunuchs (30). Likewise,
in Wagonseils description of the autopsy of a 40-yr-old eunuch, the
prostate gland was prepubertal in size (16 x 24 x 13 mm,
corresponding to a weight of approximately 4 g) (33), a finding
that is hardly surprising. However, the report by Wu and Gu that the
prostate was completely impalpable in 21 of 26 Chinese eunuchs (and
very small in the other 5) (25, 26) was unexpected and implies that
viability of the gland throughout life requires the continued presence
of gonadal hormones, presumably androgens. It is possible that very
small prostates were missed on physical examination by Wu and Gu (25, 26).
Alternatively, it is possible that disappearance of the prostate is a
function of time after castration, as the duration of castration in
their study was much longer than that in any other report, recognizing
that the duration of castration in the subset of men with barely
palpable prostates (55 yr) did not differ from that of the group
overall (54 yr).
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Comment
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Hopefully, it will never again be possible to repeat the studies
reviewed in this paper, as in more recent times we have used different
means of expressing mans inhumanity to man. It is to the credit of
the pioneering physician scientists involved that useful medical
information was obtained about the long term effects of castration,
under circumstances that must have been difficult, from the study of
these now extinct groups of castrated men, and it is impressive that
all their findings (osteoporosis, failure of closure of the epiphyses,
reactive pituitary hyperplasia, shrinkage of the prostate, and
development of gynecomastia) have been confirmed subsequently by
studies of individuals or small groups of individuals with various
forms of hypogonadism.
One question of interest concerning castration in men cannot be
resolved from the available data, namely the issue as to whether the
life span of men is shorter than that of women because of the presence
of testes or the absence of ovaries (and menstruation) (5). Indeed,
there are no valid data indicating that castration has any effect on
life span of men.
It is of some interest that no mention appears to have been made of the
relation between castration and singing in any of the literature
concerning the Chinese, Ottoman, or Skoptzy eunuchs, whereas there was
a long tradition in Italy that associated the castrated state with
phenomenal singing by men both in choirs and the opera (2). The
probable reasons for this apparent discrepancy are several. First, the
so-called castrati singers were, in fact, a heterogeneous group
consisting of women who posed as castrated men, men with hypogonadism
and/or cryptorchidism, men with intact testes who probably sang as
counter tenors or falsetto, and a few singers who either had their
testes removed or crushed (51). Consequently, it is difficult to
interpret the literature on the subject in medical terms. Second, in
the instances in which castration was performed, only boys with
extraordinary singing ability were chosen for such a procedure, and it
is likely that singing ability would be no different in men selected
for castration using other criteria than in the population at
large.
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Acknowledgments
|
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Cindy Karolikowski, Reference Librarian of the Shiffman Medical
Library in Detroit, provided invaluable assistance in the initiation of
these studies, and the assistance of Caroline Duroselle-Melish,
Reference Librarian in the Historical Collections of the New York
Academy of Medicine Library, made it possible for us to broaden their
scope. We are also grateful to reference librarians at the New York
Public Library and at the University of Texas Southwestern Medical
Center. Translations from German were made by one of the authors
(C.R.), and we are indebted to Philippe E. Zimmern for aid with the
French translations.
Received June 25, 1999.
Revised September 15, 1999.
Accepted September 17, 1999.
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