Innocence revisited – 20

A voice like a flute

I had read about the flute-like voices of the castrati of past operatic fame. And from my professional experience, I knew there was virtually no change in the voices of mature men subjected to bilateral orchidectomy for cancer of the prostate. So I concluded that to effect the voice change, castration must occur in early childhood. Certainly this seemed to be what happened until as late as the eighteenth century.

The patient across the desk in my consulting rooms in the early 1960s was an asthenic man in his late 20s. He could have passed for a teenager with his smooth face and slight build. As he told me his story, there was no doubt about the voice, although it may have sounded more like an oboe than a flute. He told me that a few years before he consulted me he had sustained a horrific injury when his pelvis was run over by a truck. This caused multiple fractures and totally eviscerated his scrotal contents. He spent a long time in hospital having multiple surgical procedures. Hormone replacement by testosterone injections and pellet implantation was plagued by allergic reactions, and finally he rejected the treatment and resigned himself to his anorchic state. All was not lost, however, as he received a handsome insurance and lump sum payout and he married the nurse who cared for him during the long months after his injury. 

The fractures had included a central dislocation of the hip, which had damaged the adjacent ureter leading to a stricture thereof; it was the associated chronic urinary infection, quite resistant to every antibiotic available at the time, that brought the patient to my attention. The affected kidney had undergone gross hydronephrotic atrophy and was without function, while the opposite organ seemed to be healthy. 

I recommended nephrectomy to protect the good kidney, but the patient said he had had enough operations and declined. In passing I mentioned that his lack of muscle bulk might be helped by some new drugs called anabolic steroids. I knew that these synthetic androgen derivatives were so-called because they induced a weight increase in the levatores ani of castrated laboratory animals when compared with that of the prostate. I prescribed a short course in the recommended dosage and arranged to reassess the patient in a few weeks. 

True to form, he failed to keep the appointment.

An unbelievable transition

When the patient next consulted me several years later I could hardly believe my eyes. He greeted me with a wide smile and a deep, booming voice and literally bounded into my consulting rooms. I can still remember the painful apposition of my metacarpal heads from his vice-like handshake.

With his insurance payout the patient had bought some trotting racehorses that provided him, he claimed, with a good living and an exciting life. Gone was the smooth face and slight build.

With some joviality he outlined his then problem by lifting his shirt and demonstrating well-developed bilateral gynaecomastia. Otherwise his secondary sexual characteristics were decidedly male. He advised me that he and his wife had an active sex life. 

It evolved that a friend who was a pharmacist had been providing an uninterrupted and uncontrolled supply of an anabolic steroid. Alas, his chronic urinary infection was still present and as anticipated it had affected his other kidney. His serum creatinine level was now significantly elevated. I suggested the possibility of bilateral simple mastectomy, but as before he declined further surgery. He died of renal failure a year or two later.

Learning from each patient 

One could speculate about what this man’s life might have been like if he had not been so badly injured, not received a large compensation payout and not taken uncontrolled and unlimited anabolic steroids. Despite good intent, I did not help him much; however, I think we should try to learn something from every patient. I learned that under special circumstances ‘anabolic’ steroids can have effects other than anabolic ones. I also learned a little from this patient about the intriguing voice of the castrati. MT