Disobedient members

Chris McManus on the black humour and blue pills of erectile woes

Impotence is "life's greatest tragedy and life's greatest joke", says Angus McLaren. And now, in addition to encompassing comedy and tragedy, this all-too-human failing has its own history - and one that I found thoroughly enthralling.

Appropriately, Impotence 's broad compass of Western history includes scenes tragical-historical, comical-historical and even - using pastoral in its spiritual sense - tragical-comical-historical-pastoral. For medieval churchmen, impotence posed theological problems, while ecclesiastical courts struggled with the practical problems of those claiming impotence, either their own or their husbands', to escape unwanted marriages. St Thomas Aquinas believed marriage was for procreation, procreation required coitus and unconsummated marriages were void, for "the marriage contract is unfitting if... one... cannot pay the marital debt". Some said they could perform but could not, and vice versa, so courts resolved the claims and counterclaims with a jury of matrons for examining the wives and "honest women" who tested out the husbands. In a scene reminiscent of a Pasolini film, one honest woman told the court in York that she "exposed her naked breasts, and with her hands warmed at the said fire, she held and rubbed the penis and testicles of the said John... in so far as she could to show his virility and potency", but he "remain[ed] without any increase".

Whosoever, be he so potent, wouldn't worry about performing under such circumstances? Once the thought of failure arises, nothing else doth rise.

Not surprisingly, the subtext throughout this book is the word anxiety.

"Why impotence?", McLaren asks on his opening page. During earlier research on fertility control, the author found many descriptions of remedies for men "to inflame their lusts and assure their fecundity" in the face of sexual failure. The resulting book is a superb history of ideas, attitudes and treatments for male sexual failure, ancient and modern. There are obligatory references to "masculinities" and "gender boundaries", but rather than the theory it is the manifold stories that impress. The conclusion may talk of masculinity being "a far more subtle and malleable ideology than many suppose", but the overwhelming impression is rather of "a preoccupation that in some ways has remained a constant" - a constant founded in human anxiety, human vulnerability and human credibility. The details are historically contingent, and temporally and geographically variable, but the forces underlying men's fear of impotence are remarkably fixed.

Impotence's fundamental joke is described throughout history, with McLaren giving accounts from Petronius and Juvenal, through Boswell and Stendhal, to George Bernard Shaw, who recorded his sexual performances as (0), (1) or (2), the quasi-vulval (0) elegantly indicating a null outcome despite a perceived possibility. Just as every great writer seems to have suffered from impotence, Baudelaire claims: "The more a man cultivates the arts, the fewer erections he has." There surely is an epidemiological study whose consummation is devoutly to be wished.

The tragedy of impotence is its unpredictability and its intractability.

Ovid describes how despite being "with the girl that I'd so often dreamed about/ Yet I lay with her limp as if I loved not". The joke comes later, when "notwithstanding, like one dead it lay/ Now, when he should not be, he's bolt upright". The implication of "he" having an independent mind, later became St Augustine's "autonomy of the penis" - confirmation of man's fall from grace, for prelapsarian Adam could control all his organs. For Montaigne, "the license and disobedience of this member" demonstrated the primary role of the mind in determining erection. Erections often occur during sleep even in those complaining of impotence, a detail noticed by Martial, who recounted how Mevius could "no longer rise... except in [his] sleep". For the 18th-century surgeon Astley Cooper, nocturnal erections in impotence effectively excluded organic pathology and pointed the finger of blame firmly at the psyche. Hence the diagnostic use of the "nocturnal mensurator" in Kingsley Amis's mordant novel Jake's Thing .

With mind prepotent over body in causing impotence, it is no surprise that for millennia doctors made fortunes from quack remedies, since various combinations of the placebo effect, misplaced attributions, embarrassment and the odd dose of luck inevitably meant that some remedies seemed efficacious. Despite so many supposed therapies, medicine actually understood little about impotence, and almost nothing was taught in medical schools. All I remember from three decades ago is the old medical joke of the only effective treatment being celery - used as a splint. The idea was not new, with symbolism or crude mechanics underpinning most remedies throughout history, as when Pliny recommended leeks, or others recommended the testicle-like roots of orchids, or onions and garlic for producing gas to inflate the penis. With safe, pain-free surgery in the 19th century, surgeons devised novel and profitable operations for impotence, the most infamous being the Steinach operation of unilateral vas deferens ligation - that is, half a vasectomy. Introduced in 1918, the patient remained fertile, but the reduced sperm and semen loss supposedly benefited the "spermatic economy", boosting male hormones. Although much mocked, Eugen Steinach, as McLaren emphasises, was a serious scientist who was nominated 11 times for a Nobel prize. Before randomised controlled trials, such operations were difficult to evaluate, although the editor of the Journal of the American Medical Association effectively damned the operation by emphasising how patients vasectomised for prostate problems reported no sexual rejuvenation because they did not expect to.

Ultimately, impotence is a mechanical problem in what Erasmus Darwin called "a wonderful machine", the hydraulics of which were described by Albrecht von Haller in 1747. The scope even in modern times for misunderstanding the near bone-like hardness is shown in a memory of my grandmother pointing to a skeleton's pelvis and whispering that a midline bone had been omitted. To complicate things, most mammals do have a baculum or penile bone. Running the length of the human penis, the spongy lacunae of the corpora cavernosa inflate to arterial pressure when smooth muscle relaxes in the lacunae, allowing blood to flood in. In a neat positive feedback mechanism akin to the valve on a bicycle tyre, penile pressure then forces shut the outflow veins, increasing turgidity and rigidity and proving success is its own reward. The show finishes as the adrenaline surge of ejaculation once more contracts the smooth muscle, blood flow drops and detumescence follows. Of course, anxiety's adrenaline can also prevent the show ever starting.

The hydraulic basis of erection may have been well understood, but interventions to ensure it were but a limp success. In the 1970s, American surgeons implanted a panoply of mechanical devices, culminating in the ingenious "700 Ultraflex Inflatable Penile Prosthesis" with its reservoir and pump hidden in the scrotum. Such devices, McLaren says, "produced a formidably rigid member reminiscent of the body parts of the robot played by Arnold Schwarzenegger in... The Terminator ". A quarter of a million patients, paying $5,000 (£2,500) each for these devices for their desires, testified how desperate were the afflicted and how lucrative was the market.

Progress, as so often in pharmacology, was serendipitous. A French researcher, Ronald Virag, "accidentally" injected papaverine into a patient's penis, producing an erection. Pharmacologists now became interested, the most intrepid being the distinguished British physiologist Giles Brindley, who self-injected many substances. At a now notorious evening lecture in 1983 to the Urodynamics Society, fittingly in a Las Vegas hotel, Brindley, then in his late fifties, shuffled in wearing a tracksuit. His slides of penises made erect by injections not having sufficient impact, he then explained that half an hour earlier he had injected papaverine into his own penis. He then dropped his trousers, waddled down the stairs from the platform and showed the audience the impressive result. This bravado performance, in what surely would normally be a most deflating situation, confirmed pharmacology's role in treating impotence. In 1995 Caverject (alprostadil) came onto the market, although as McLaren says, the "most obvious drawback was... what... for most men was a nightmare scenario, the plunging of a needle into their penis".

Serendipity also played a role in a Pfizer trial of a treatment for angina.

Although technically "side-effects", the erections reported by trial subjects were unusual because those affected refused to return their pills.

The drug that relaxed the penile smooth muscle was sildenafil, or Viagra, which made Pfizer $1 billion in 1999 alone, and in 2007 was used by 900,000 British men. Although it has been commercially successful, evaluating its true efficacy is less easy, a telling statistic being that only half of Viagra prescriptions are subsequently renewed, while wives complain of intimacy lost to mere performance. Originally marketed for "erectile dysfunction", the diamond-shaped blue pills are now recreational drugs, although gays are apparently suspicious of an overly hard penis and of being "pill-fucked". Is this the beginning of a Campaign for Real Sex or a Movement for Slow Sex? Either way, like all pharmacological innovations, Viagra needs placing in its cultural and historical context, and as is shown by the wealth of material given here, there is no finer place to start than this book.

Chris McManus is professor of psychology and medical education, University College London.