Mind of Its Own : A Cultural History of the Penis

Chapter 6: The Punctureproof Balloon

Farther down the Strip, Siegfried and Roy were making a tiger vanish into thin air, Sammy Davis Jr. was belting "I Gotta Be Me," and two circus aerialists -- one sitting on the other's shoulders -- walked fifty yards of tightrope without a net. But even in Vegas they'd never seen a show like this.

The year was 1983, the showman a complete novice. But this was no Open Mike Night. The person on stage, a Briton named Giles Brindley, was a professional -- a physician, in fact. The Nevada desert was blooming with conventioneers and Dr. Brindley was in town to address several thousand members of the American Urological Association. That's a hall full of men who examine prostates for a living. In Vegas they call this a tough room. Even so, Brindley wasn't nervous. He had presented numerous papers at scientific meetings like this in Europe, where his reputation for original research, especially in bioengineering, was legendary. In 1964 Brindley invented the world's first visual prosthesis. Three pairs of electronic eyes were implanted in human volunteers before the project was terminated because of high costs and low effectiveness. Still, Brindley's design concept impressed his peers as a major theoretical breakthrough, perhaps a work of genius. Unusual physiological questions had always piqued Brindley's curiosity. Once, while traveling in a car, he dropped a rabbit from the roof to the floor whenever the auto made a sharp turn. Brindley wanted to see how centrifugal force affected the creature's ability to land on its feet. The car, it should be noted, was moving nearly eighty miles per hour at the time.

On this particular night in Nevada, Brindley was standing still behind a podium. Lately he had been concentrating on physiological problems of the male human. The buzz from London was intriguing. Brindley, who begged off speaking at a similar conference months earlier because of pressing research, was rumored to be experimenting with drugs that produced an eye-opening result: when injected in the penis they created an erection that lasted for hours. This supposedly had occurred in men who were impotent for decades, even in men who were paralyzed. If Brindley had really done this, he had solved a physiological mystery that had been unsolved for thousands of years. But the full significance was even greater. If true, Brindley's feat did more than stretch the limits of being a medical man. It stretched the limits of being a man.

Impotence had only recently become a serious subject of inquiry for urologists. For much of the previous century, they had waged a halfhearted, and ultimately unsuccessful, struggle with psychiatrists for primacy in the field of male sexual functioning. After Freud, impotence was seen by most patients and healers as a mental problem. This was fine with most urologists, who were happy to specialize in removing stones, treating incontinence, and shrinking swollen prostates. In the 1970s, however, technical advances gave these surgeons new impotence therapies that, while extreme, actually worked. One was the inflatable penile implant. The other was revascularization, a procedure that rewired the arteries through which blood enters the penis in an operation not unlike a heart bypass.

In 1983 rumors of Brindley's drug experiments provoked skepticism among doctors committed to those new treatments. One urologist approached Brindley at the Las Vegas convention and challenged him to prove his drug therapy's effectiveness beyond charts, tables, and graphs. Brindley, a former competitive athlete, decided to do just that. The result was perhaps the most memorable public moment in all of modern medicine. After calmly presenting his data from behind the podium, Brindley stepped in front of it and pulled down his pants. Moments earlier, you see, he had gone to the men's room and secretly injected himself. And now, before a room full of strangers, there it was: the, uh, "evidence."

The audience gasped. Brindley did not want the urologists to think he was fooling them with a silicone prosthesis, so he headed into the crowd, proof in hand, and asked them to inspect it. "I had been wondering why Brindley was wearing sweatpants," says Dr. Arnold Melman, chief of urology at New York's Albert Einstein College of Medicine, who was there. "Suddenly I knew." Some urologists accepted Brindley's offer, slipping on their eyeglasses to get a better look. Never before had so many penis doctors seen another man's erect penis. And in this singular moment, human sexuality, the healing profession, and man's relationship with his penis underwent a huge transformation, the consequences of which are still being felt today.

This is because Brindley did more than give new meaning to the term scientific presentation. He gave birth to the newest idea of the penis: a totally medicalized organ stripped of its psychic significance and mystery and transformed into a tiny network of blood vessels, neurotransmitters, and smooth-muscle tissue knowable only to a credentialed scientist. This white-coated expert sets standards for the organ's size and rigidity against which all erections must be measured, and decrees any variation from that norm is a disease. The organ's intrinsically finicky nature -- that constant of human history -- has been redefined as a pathology addressable only by drugs and/or surgery.

This penis is impervious to religious teachings, Freudian insights, racial stereotypes, and feminist criticism. It is no longer part of a human dialogue. It is a thing -- a virtually punctureproof balloon that can be reinflated at will, no matter how often it has gone flat in the past, or why. Man's testy relationship with his defining organ has been medically pacified. The longest power struggle in every man's life is over, the uncontrollable has been brought to heel, and the ultimate male fantasy has come true: A penis that is hard on demand, potentially hard for hours, and definitely hard enough to satisfy the most demanding women. Maybe even a bunch of them.

Now urologists see erect penises all the time. They create them in their offices, then show patients how to re-create them at home using the drug therapy pioneered by Brindley and others. Transurethral pellets can now achieve the same result without a needle, and, on March 27, 1998, the Food and Drug Administration gave its sanction to Viagra, the first oral agent approved to treat erectile dysfunction (ED). The astonishing medical, social, and commercial success of Pfizer's little pill -- Viagra has been taken by more than 7 million men, producing annual revenue estimated at $1 billion -- has led to the rapid expansion of an erection industry. This commercial alliance of ED specialists and drug manufacturers (the latter hire the former as consultants and supply the funding for nearly all the research done in the field) is now seeking faster, longer-acting, and even more profitable medications, a quest the psychologist and social critic Leonore Tiefer has called "the pursuit of the perfect penis."

The lucrative new therapies developed and marketed by Pfizer and others are covered by the media as a personal-hygiene update for the estimated 30 million Americans who struggle with erectile dysfunction, a number supplied (critics say "fabricated") by the very erection industry that profits from identifying those men as patients. There is no doubt that these erection drugs have helped millions -- Viagra works -- not to mention the millions more who own drug-company stock. But this coverage misses the larger point. The erection industry is more than just a health or business story. It is the latest, and perhaps final, chapter in the story of man's relationship with his penis.

The recorded history of impotence treatments is nearly as old as recorded history. Ancient medical texts reveal that not long after man discovered his penis could get hard he began to fret about it staying soft. Respect for the former condition, and fear of the latter, led to numerous cures, many applied to the organ directly. An Egyptian papyrus from around 1700 B.C. recommended the following poultice: "One part leaves of Christ's-thorn; one part leaves of acacia; one part honey. Grind the leaves in this honey and apply [to penis] as bandage." Clay tablets from the Tigris-Euphrates Valley (ninth century B.C.) tell us that Assyrian physicians had their limp patients eat dried lizard and cantharides. That second substance, made from crushed beetles, has an inflammatory effect on a man's genitourinary system that the ancients and not-so-ancients mistook for revived vigor. (Many centuries later Europeans called it Spanish fly.) Those Assyrian healers also urged an impotent man to have a woman rub his penis with a special oil flecked with bits of pulverized iron. For best results it was recommended she do this while chanting "Let this penis be a stick of martu-wood" and "Let this horse make love to me." Apparently the power of positive thinking -- and flattery from females -- has a long history indeed.

The Hindu Samhita of Sushruta (circa 1000 B.C.) mentioned several impotence remedies, most of them to be eaten. "By eating the testes of a he-goat...fried in clarified butter prepared from churning milk," the Samhita said, "a man is enabled to visit a hundred women one after the other." Early Western cultures also consumed animal testes to restore or improve potency. The Greek physician Nicander (second century B.C.) recommended those obtained from a hippopotamus, a prescription that no doubt required a wealthy client list. It seems there were many industrious erection entrepreneurs among our ancient ancestors, but the true forefathers of the modern erection industry are found in the nineteenth century, when some Western urologists devised treatments that today seem (at best) hilarious and (at worst) barbaric. It was not a good time to be an impotence patient. But it was an excellent time to be a quack.

This was because even well-educated, legitimate doctors did not understand the physiology of erections very well. Thanks to pioneers such as Leonardo da Vinci, Ambroise Paré, and Regnier de Graaf they knew an erection was produced by a surge of blood. But they did not know how that blood got there or what kept it there once it arrived. The sixteenth-century anatomist Costanzo Varolio attributed the ability of the penis to rise to "erector muscles." Most doctors still believed this three centuries later, though the mechanism of those muscles had never been conclusively demonstrated. It was not until 1863 that German scientist Conrad Eckhard showed the role of the nervous system in erectile functioning. He did this by applying electric current to the pelvic nerves of a dog, who responded by becoming erect. "That there is a neurological aspect to the erection process seems like common sense now," says Dr. Arthur L. Burnett, director of the Male Consultation Clinic at Johns Hopkins University. "But you have to realize our understanding of erections has gone through a long evolutionary process. It was once thought that spirits controlled erections and that the penis was filled with air. Much of our scientific information about erections is less than two hundred years old. A lot of it is less than twenty years old."

In the nineteenth century this combination of some good information, with lots of bad, led to some bizarre and painful impotence treatments. One of the most honored physicians in America then was Samuel W. Gross, author of A Practical Treatise on Impotence, Sterility and Allied Disorders of the Male Sexual Organs, published in 1881. Gross was professor of surgery at Jefferson Medical College in Philadelphia, just as his father, Samuel D. Gross, had been before him. (The artist Thomas Eakins immortalized both doctors -- focusing on the father, from whom he had taken an anatomy class -- in his 1875 painting The Gross Clinic.)

The younger Gross, like many of his peers, was convinced of the link between erectile failure in intercourse and masturbation. Gross specifically attributed impotence to "strictures" inside the base of the penis, where the urethra is ringed by the prostate gland. These strictures, Gross said, were the result of inflammation and swelling of the prostatic urethra, a condition he called "prostatic hyperaesthesia," caused by self-abuse or involuntary night "pollutions." Gross made this diagnosis by inserting a long, thin, nickel-plated instrument called a bougie down his patient's urethra. As he conceded on page 34 of A Practical Treatise, this procedure was not always a pleasant experience for the person bougied.

Case XIII. A mechanic, twenty-three years of age....Examination with a No. 25 explorer [the bougie] disclosed intense hyperaesthesia of the entire urethra, and particularly of its prostatic portion....As soon as the instrument entered the passage it occasioned tremor and retraction of the testes, and when it reached the prostatic portion [the patient] shrank from the excessive suffering from which it awakened, and the muscles of the lids, nose, and mouth twitched convulsively. On its withdrawal, the bulb [at the tip of the bougie] brought forth a considerable prostatic discharge. [The patient] afterward rode to his home on street cars, and about two hours later, after urinating, was seized with a curious crawling sensation in his arms and legs, lost consciousness, and, when found by his friends, was lying on the floor, his face livid.

Amazingly, this patient returned to Dr. Gross to have his condition treated, which meant several more intimate invasions. Blasts of hot and cold water were sent down his urethra, a hot rubber plug was jammed into his rectum, and the bougie was reinserted after being dipped in corrosive chemicals.

In cases that still failed to respond, many urologists used a method inspired by Varolio's sixteenth-century anatomical speculations and Eckhard's more recent experiments on dogs: they applied electricity to the (mythical) erector muscles inside the penis. The first step in this procedure required the doctor to insert a twin-pronged metal instrument, shaped like a tiny pitchfork, handle-first into the meatus (pronounced me-ATE-us) of the penis, the place we nonurologists call "the hole." The prongs were connected to a small generator, which was then turned on and off. An illustration in a contemporaneous urology textbook shows the treatment to resemble our current practice of restarting a car battery with jumper cables. Many doctors touting electrotherapy sold the machines providing current to the disabled penis or wrote books extolling the virtues of the treatment. Very few of them lost money at it.

You might think impotence therapy couldn't sink lower than penile electroshock or chemically spiked bougies. But you would be wrong. In the early twentieth century, doctors began doing testicle transplants.

What seems Frankensteinish to our ears had its roots in a mixed soil of old superstitions and new science. In Emperor Nero's day, orgies were often fueled by the Viagra of ancient Rome -- liquids made from the crushed testes of goats or wolves. Such preparations could not have had any real effect, except as early testimony to the power of placebos. But the enduring nature of that effect no doubt explains why medieval physician Johannes Mesue the Elder was still prescribing testicular extracts eight centuries later -- or why, eight centuries after that, the English medical reference Salmon's Dispensatory endorsed the use of testes extracts from dozens of species.

Aper, the boar: the stones and pizzle dried, and given in powder, help weakness and barrenness. Canis, the dog: the testicles and secretion provoke lust....Buteo, the buzzard: the testicles help weakness of generation.

An understanding of the true androgenic role of testicles (that is, on secondary sex characteristics such as facial hair) was not achieved until 1848, when the German physiologist Arnold Berthold did the following experiment on six freshly castrated roosters. Two of these birds had one of their own testicles returned to their abdominal cavity; two others had testes from another bird in the experiment implanted in them; the remaining two were left castrated, as controls. Berthold saw that the comb and wattle of his castrated birds quickly deteriorated after surgery, but returned to normal in the birds that had been "re-testified." He attributed this, correctly, to "the productive function of the testes, i.e., by their action on the blood stream, and then by the corresponding reaction of the blood upon the entire organism."

This experiment is now considered one of the founding acts of modern endocrinology. Unfortunately, it was ignored for the next fifty years. As a result, ignorance of the testes' true function, and misconceptions about their potency-restoring properties if eaten, continued. Thus, when Charles Brown-Sequard, one of the world's most respected physicians, said he had rejuvenated his own sexual powers in 1889 by ingesting a potion made of crushed dog testes, one circle dating back to the ancients was completed, and a new one, thankfully of much shorter duration, was about to begin. Weeks after his "rejuvenation," Brown-Sequard was mailing vials of his liquide testiculaire (obtained from dogs or guinea pigs) to any physician who wanted to experiment with it. When these doctors were unable to replicate his results, they concluded the problem was not with the concept, but with the materials: the extract was too weak. What was needed, they thought, were actual testes.

As it happened, the first testicle transplant in the medical literature was not about sex. At least not directly. The patient seen by Drs. Levi Hammond and Howard Sutton in Philadelphia in November 1911 was a nineteen-year-old boy who had been kicked in the scrotum, after which one of his testes had swollen by more than ten inches. The doctors' original plan, motivated primarily by aesthetic concerns, was to replace that testicle with one from a sheep. But a day before that was to happen, a human testicle became available from a young man who bled to death. Somewhat impulsively, the surgeons decided to use it. They removed the testicle from the donor, flushed it with sterile saline, stored it overnight in a glass jar at forty degrees Fahrenheit, then transplanted it into their patient the following morning. (This appears to be the first transplant of any human organ in the medical literature.) A month later, however, the doctors were disappointed to see that their transplant had atrophied considerably. Hammond and Sutton never published a follow-up. Knowing what we know now, it is safe to say the transplant was rejected.

But the fact of tissue rejection -- indeed, the very idea of the body's immune system -- was not yet well-understood, so testicle transplants continued. Chicago urologist Victor Lespinasse claimed to have performed a transplant several months before Hammond and Sutton, reporting his results in Journal of the American Medical Association and Chicago Medical Report a few years later. Unlike Hammond and Sutton, Lespinasse's goal most definitely was improving sexual function. But rather than transplanting an entire testicle, as the Philadelphians had done, he carved the donor's testicle into slices, then grafted them into muscle tissue in and around the recipient's scrotum. This is how Lespinasse described the procedure in 1914:

A man, aged 38, consulted me in January, 1911, to find out if anything could be done for the loss of both testicles. One testicle was removed during a hernia operation; the other had been lost in [an] accident....He was unable to have intercourse, which was his chief reason for seeking medical advice....

A testicle from a normal man was easily obtained....The two patients were anesthetized at the same time, and the recipient prepared as follows: The scrotum was opened high up and a bed prepared in the same way as we prepare the bed for the reception of an undescended testicle....The fibers of the rectus muscle were exposed and separated...and then the testicle to be transplanted was removed. It was stripped of the epididymis...and then sliced transversely to its long axis [in slices] approximately 1 mm. thick. The central slice and the one next to it were taken out and placed among the fibers of the rectus muscle. Another slice was placed in the scrotum.

Lespinasse wrote that he was "surprised at the number of testicles that are available for transplantation purposes." He made no mention, however, if (or how much) those living donors were paid for their services.

Four days later Lespinasse's patient "had a strong erection accompanied by marked sexual desire. He insisted on leaving his hospital bed to satisfy this desire." This the patient did -- and continued to do so, Lespinasse reported, for the next two years, after which the surgeon lost contact with him. Even so, Lespinasse was reluctant to take all the credit. "The sexual function is about nine-tenths psychic," he wrote, "and how much is due to the strong mental stimulus engendered by the operation, and how much to the actual functioning of the [grafted testicular] cells, is impossible to determine."

That uncertainty did not stop Lespinasse from doing more transplants. In 1922 one of his gland-grafting cases made the front page of the New York Times, no doubt because of the identity of his patient, the chairman of the International Harvester Corporation -- the IBM of that era -- Harry F. McCormick. The fact that McCormick, then fifty-one, was married to Edith Rockefeller, daughter of John D., made him one of the richest men in the world twice over. That he was carrying on a well-publicized love affair with a beautiful European opera star made him even more newsworthy. The headline and subheads in the Times piece read, "SECRET OPERATION FOR H. F. M'CORMICK / Family Refuses to Say Whether His Stay in Hospital is for Gland Transplanting / KEEPING YOUNG IS HIS HOBBY / Lespinasse, His Surgeon, A Leader in Rejuvenation, Also is Silent on Case." The donor was rumored to be an Illinois blacksmith. True or not, the following ditty, inspired by verse by Henry Wadsworth Longfellow, was soon heard in taverns all across America:

Under the spreading chestnut tree,
The village smithy stands;
The smith a gloomy man is he,
McCormick has his glands.

Lespinasse was certainly getting famous for his work, but a colleague in Chicago had gone him one better. In 1920 Dr. G. Frank Lydston informed the press that he had transplanted a testicle into himself. Lydston wrote in the Journal of the American Medical Association of nine other grafts, eight done by him on volunteers, the other done by Leo L. Stanley, chief surgeon at California's San Quentin prison. Dr. Stanley had no shortage of freshly deceased donors -- inmates were executed often at his place of work. Lydston's JAMA report on one of Stanley's cases, based on facts given him by the prison doctor, is a peerless blend of optimism and condescension:

Case 9 -- A man, aged 25, evidently a moron, committed for burglary, had been kicked in the testicle five years previously....At the time of operation the testes were the size of olive pits. The patient was tall, thin, anemic, very dull and apathetic....The donor was a negro hanged for murder. The glands were removed...fifteen minutes after death...refrigerated...[and implanted several hours later....] Seven weeks after the operation the doctor reported that the testes were firm and..."resting nicely in the scrotal sac." The patient gained fifteen pounds and had become active and alert -- in fact, he was improved in every way -- and sexually had become very active....Dr. Stanley said: "He now has erections nightly and in the daytime, something he never had before."

In the "comment" section of his JAMA piece, Lydston noted the cross-racial aspect of Stanley's case. Lydston's fascination with the donor's race and the recipient's improved sex life (in an all-male prison population!) reflected an enduring interest of his. In 1893 he cowrote "Sexual Crimes Among the Southern Negroes -- Scientifically Considered," an article calling for the full "Oriental" castration -- testes and penis -- of any Negro convicted of raping a white woman as the only effective punishment. Clearly, Dr. Lydston spent a lot of time thinking about black genitalia.

Lydston went public about his surgery on himself because, as the 1920s moved along, the most celebrated testicle transplanter in the world became a publicity-seeking, Russian-born surgeon working in Paris named Serge Voronoff. Ever the jingoist, Lydston wanted to remind the world that gland grafting had started in the good old U.S.A., where dozens of surgeons were doing the procedure and promising great results to all comers. That fact was certainly true, but it failed to halt Dr. Voronoff's publicity juggernaut. This wasn't because Voronoff was doing more testicle transplants than anyone else. It was because he didn't bother to use humans as donors.

In 1925 a book newly translated from French into English opened with perhaps the most jaw-dropping first paragraph in all of medical literature. "Between the 12th of June, 1920, and October 15th, 1923, I performed fifty-two testicular grafting operations" on human males, Serge Voronoff wrote in Rejuvenation by Grafting. "In all [but one case], the grafts were obtained from apes."

It is impossible to exaggerate the shock and fascination with which these words were received. Though other surgeons had preceded him, Voronoff instantly became the most famous testicle transplanter of them all. He had not been totally unknown; in France Voronoff had grafted testes tissue from young rams into older ones, after which, he told the press, the recipients showed clear signs of rejuvenation. When asked by a New York Times reporter in 1922 when he would start working with humans, Voronoff said, "Soon." "Grafting can only be done with beings of the same species," the Russian said, "but with men it is a rather difficult situation, as you cannot remove the source of vigor from a young man for the sake of making an old man young." (Clearly, Dr. Lespinasse in Chicago felt differently.) "But it is possible," Voronoff said, "to use monkeys, as they are akin to men." This was not the answer the Timesman was expecting.

"But if you graft a monkey's glands in the body of a man, [won't he] become a monkey?" he asked.

"It would not be the case at all," Voronoff promised.

About that, and not much else, Voronoff was correct. On June 20, 1922, he was again quoted in the Times, saying he had made good on his vows. Voronoff had placed testicle grafts in several men who, afterward, remained totally human but dramatically improved over their previous state, especially sexually. The donors for all these transplants, Voronoff said, were African chimpanzees.

Voronoff had become interested in a possible link between testes and rejuvenation in 1898, while working as a physician in Egypt, where he examined several eunuchs. He was struck by their obesity, hairless faces, and developed breasts. But, most of all, Voronoff was impressed by how old they looked. "The hair grows white at an early age, and it is rare for them to attain old age....Are these disastrous effects directly due to the absence of the testicles?" he later wondered in print. And might not aging in a normal man be attributable to old, weak testes?

Voronoff was certain his subsequent animal experiments proved his Egyptian musings had been prescient. Actually, they proved no such thing, though the blame for that error must be shared with Edouard Retterer, a Parisian pathologist. In France Voronoff had operated a second time on one of his first patients -- Old Ram No. 12 -- a year after the initial surgery and removed the graft for examination. Because Voronoff was not an experienced microscopist, he turned this tissue over to Retterer, who was. Unfortunately, Retterer mistook the invading cells of the sheep's immune system at the graft site as evidence of the survival of the graft itself.

Once he started operating on humans, Voronoff, as Lespinasse had before him, grafted thin slices of a testicle into the recipient. Unlike Lespinasse, however, Voronoff sutured his monkey tissue directly onto the tunica vaginalis, the thin serum-filled pouch that encases each testis, rather than embedding it in muscle tissue inside the scrotum. Voronoff prepared the tunica for the graft by gently scratching its surface with a sharp surgical instrument. The resulting grooves formed a bed for the monkey graft; equally important, the flow of blood serum out of the scratches, Voronoff believed, nourished the graft and kept it alive. He had raked the tunicae of his rams in his first experiments. The fact that Retterer pronounced those grafts still functioning years later convinced Voronoff his theory was correct.

Rejuvenation by Grafting is a thoroughly compelling document, made all the more so by its unpretentious style. "It is not possible to get the ape onto the table while conscious, as even the gentlest subjects fight desperately [any] attempt to tie their limbs," Voronoff wrote. "They are extremely suspicious and, in order to anaesthetize them, it is necessary to resort to strategy." One of Voronoff's associates designed a strategic cage that closed by means of a double trapdoor.

One shutter of the trapdoor is an open trellis permitting free access of air to the ape, while the second shutter is solid. The latter is lowered just before the cage is saturated with the anaesthetic.

A small window in this "Anaesthetizing Box" enabled Voronoff to see when the ape was dazed. "No time must be lost" at this moment, he warned. The ape "must be got out of the cage and onto the operating table...before he is sufficiently recovered to get his teeth into the hands of those who control him."

Once there, the ape was administered chloroform, after which his four limbs were spread out and tied down. Then an extensive pre-op session began. "Owing to [the ape's] uncleanly habits, meticulous care" was taken to shave the "scrotum, the lower part of the hypogastrium and the upper portions of both thighs; they must be well scrubbed with soap and hot water, washed with plenty of ether or spirit, and carefully painted with tincture of iodine," Voronoff wrote. On a table several feet away, the human recipient was similarly prepared. One assumes he escaped the indignity of the "Anaesthetizing Box" and -- it is hoped -- required less scrubbing and shaving.

After this, a testicle was removed from the ape by Voronoff's cosurgeon, who cut that testis into two halves, then cut three slices from each half. As this was happening, Voronoff prepared the human recipient, opening his scrotum, and exposing the tunicae vaginalis inside. Voronoff scratched the first tunica, prompting the flow of blood serum. Then he took the three monkey grafts prepared by his cosurgeon and sewed them onto its grooved surface, ensuring that none of the grafts was in contact with another. He then repeated this procedure on the other tunica. All of these steps were demonstrated in Rejuvenation with lifelike illustrations.

Most people, however, learned about Voronoff's operation in the popular press. Several monkey-gland recipients were practiced boulevardiers before the surgery; afterward, newspapers noted approvingly, their success rate as seducers soared even higher. The German humor magazine Simplicissimus ran a cartoon showing Voronoff's operating room crowded with a pregnant woman and dozens of her scrawny children, many with their hands in a supplicant's position, begging the surgeon not to operate on the ape sitting on his operating table, or their father, lying nearby. "Professor, please," the caption began, "wouldn't you rather use a method that prematurely makes our father older?"

Voronoff's operations were soon mimicked in America. Max Thorek, the esteemed physician who later wrote The Human Testis, spent much of the 1920s supplying his patients with slices of monkey testes. He had a small zoo built on the roof of a Chicago hospital to house his donors. One Sunday morning the monkeys escaped, gathering minutes later, for no known reason, at a nearby Catholic church. In his memoirs Thorek declined to describe in print "the sacrilegious actions" of those beasts, witnessed by a packed house of shocked congregants. Strange things with animals were also occurring in rural Kansas. There "Dr." John R. Brinkley got rich grafting goat testes into human patients. Unlike Voronoff and Thorek, however, Brinkley's credentials were highly suspect. In fact, it appears he bought them.

In England Voronoff's procedures inspired a novel called The Gland Stealers, issued by the same house that published P. G. Wodehouse. "Gran'pa is ninety-five, possessed of £100,000, a fertile imagination, and a good physique," the promotional copy on the book jacket began. "He sees in the papers accounts of Professor Voronoff's theory of rejuvenation by means of gland-grafting. Nothing will satisfy him but that the experiment should be made on himself....

He acquires a gorilla, a hefty murderous brute, and the operation is performed with success. That is only the beginning....Inspired to philanthropy by the thrill of regained youth, Gran'pa decides to take a hundred or so old men to Africa, capture a like number of gorillas, and borrow their glands....

In this case fiction reflected fact: Voronoff's operation became so popular that the French government felt compelled to ban monkey hunting in its African colonies.

The press marveled at Voronoff's extravagant lifestyle -- the huge hotel suite on the Champs-Elysées, where he lived with his wife and a staff of servants, his holiday home on the Riviera, the fancy cars and parties, etcetera. Voronoff could certainly afford it. He charged $5,000 per surgery, a prodigious sum eighty years ago. By the end of 1926, Voronoff said he had done one thousand of them.

The enduring power of the placebo effect is certainly one reason why Voronoff was so successful. The surgeon's career was also given a boost by the then-burgeoning eugenics movement. Because World War I "destroyed a fit elite and left behind a degenerating, elderly rump," David Hamilton writes in The Monkey Gland Affair, "Voronoff's efforts at rejuvenating the aging wealthy classes was [seen as] a step in the right direction." At the same time, recent advances in plastic surgery and orthopedics led many to believe, as British scientist Julian Huxley did, that "biological knowledge enable[s] us to modify the processes of our bodies more in accord with our wishes." Just about everything was deemed malleable in the hands of the scientist. Why not add man's testes to that list?

Because, in the end, it was proved that Voronoff's operation did not work. One would hope to learn this sorry episode was ended by one of Voronoff's medical peers, after putting Voronoff's claims to rigorous scientific scrutiny. But that was only partly the case. In truth, few medical doctors ever challenged Voronoff's claims. The scientist who finally did prove the futility of Voronoff's testicle grafts was a French veterinarian, working in Morocco, named Henri Velu. In the late 1920s, Velu re-created Voronoff's early experiments on rams. After performing his own testes grafts, Velu removed them months later and examined them himself under a microscope. He concluded, correctly, that the "graft" was really a scar plus some inflammatory cells, the latter a remnant of the "invading force" that had successfully rejected the graft. Testicle grafts, Velu wrote in 1929, are "une grande illusion."

Skepticism regarding Voronoff's work finally began to grow, and Velu's findings were confirmed by subsequent medical advances. After testosterone was isolated in 1935, scientists demonstrated its inability to reverse the aging process or, by itself, to restore potency to a dysfunctional man who was otherwise healthy. In the next decade biologist Peter Medawar's work on the immune system proved that any and all of Voronoff's grafts would have been quickly destroyed by the host. (Professor Medawar was later awarded the Nobel Prize.)

There are conflicting reports of Voronoff's state when he died in 1951, at eighty-five. In Medical Blunders, Robert Youngson and Ian Schott wrote that "Voronoff lived to be ridiculed, but bore it with dignity." But Patrick McGrady, in The Youth Doctors, quoted a Swiss physician who knew the monkey-gland doctor as saying Voronoff was severely depressed near the end. Not because of what happened to him, the Swiss said -- because of what may have happened to his patients because of him. Apparently, Voronoff feared that several of his grafts may have transferred syphilis from his apes to his human recipients. Voronoff was horrified by this thought, the Swiss said, and spent much of his final days in depressed isolation because of it. Only one thing is certain: depressed or not, the pioneer in the erection industry named Serge Voronoff died an extremely wealthy man.

In 1934 a psychiatrist stood up at a meeting of primary-care physicians in New York and urged them to refuse to send any of their impotence patients to a urologist -- or any surgeon for that matter -- for fear of doing them irreparable harm. This skirmish in the turf war between psychiatrists and urologists had begun in earnest seven years earlier. In Impotence in the Male, psychiatrist Wilhelm Stekel declared there is no such thing as "organic impotence," save for the 5 percent of cases in which patients have damaged or diseased genitals. Stekel was extrapolating from personal experience: his own impotence had been cured on the couch in Vienna by Sigmund Freud. (Interestingly, Freud later came to despise Stekel, and banished him from his inner circle.)

Stekel's personal problems with Freud did not lessen his enthusiasm for Freudianism. Stekel insisted that, in the remaining 95 percent of impotence cases, the disease is entirely psychological, caused by self-hatred produced by unresolved Oedipal issues, unconscious fears and anxieties arising from childhood sexual disturbances, and inhibitions reinforced by religion and/or secular morality. The physical power of erection in men is given to them at birth, Stekel wrote, and is "preserved until death."

Stekel's 95 percent figure was soon accepted as fact, though there was no epidemiological evidence to support it. Nor was there any hard data that the talking cure used by psychoanalysis was of any lasting benefit in impotence cases, either. Many of the case reports in the medical literature now seem comical, misogynistic, or both. The following was written by Dr. B. S. Talmey, in the New York Medical Journal.

Mr. X., thirty years of age, was as a young boy regularly taken to the Tyrolean mountains [for his] vacation. When he was fifteen...he lived with his parents near an Alpine dairy where he roamed around among the cows and became quite attached to a pretty, twenty-year-old dairy maid who, on her side, took an erotic fancy to the handsome boy.

One day, while young Mr. X. was sunning himself near the grazing cows,

she joined him and taught him the ars amandi. This she repeated every day as long as the vacation lasted. [Later,] when Mr. X. married, he found that conjunction was possible only if his wife was attired in Tyrolean peasant costume and assumed the same posture as his pretty dairy maid years ago....In the beginning of their married life...the wife granted his requests. The erections were perfectly normal, and two children were born. Lately the wife has rebelled against the masquerade, and Mr. X. found himself completely impotent. In the lupenar where, for a remuneration, anything can be obtained, he has violent erections with a [prostitute] dressed as an Alpine dairy maid.

Dr. Talmey's response was to accuse Mrs. X. of a "sanctimonious frigidity" he said he often found in upper-class wives. Such women think that "assuming the supine position and [a state of] femoral divergence are the only contributions" to intercourse required of them. To help her husband's impotence, Talmey said, Mrs. X. must improve her attitude and don that damn peasant blouse. If not, she was dooming him to more visits to the lupenar, where the outcome would be even more impotence. "Extreme excitement after long abstinence," Talmey wrote, causes serious erectile dysfunction.

The expectancy and joy over the final reaching of the goal causes a great nervous disturbance within the inhibitory center which becomes overexcited, and at the critical moment the erections fail, the penis becomes flaccid, and shrivels to half its normal size.

In 1936 New York urologist Max Huhner had read enough. He challenged Karl Menninger, head of the famous psychoanalytic clinic in Kansas that bore his name, to a debate on impotence therapy in the Journal of Urology. Menninger, who went first, argued that even when interventions such as the cauterization of the prostatic urethra produced the resumption of erectile functioning, they only did so because of their psychological effects. "The patient thinks there is something wrong with his genitalia," Menninger wrote. Urologists "know this is not true, or at least, that the organ pathology is secondary to the psycho-pathology, but experience has taught them the curative value of treating the genitalia locally, and by its suggestive value reassuring the patient and relieving his anxiety and thereby his impotence." The reality of the situation, Menninger said, is that impotence is caused by anxiety, a condition best treated by psychoanalysis. The talking cure made conscious "the unconscious emotions that often (always?) determine the inhibition of sexual functioning." The specific nature of those negative emotions, Menninger wrote, include "fears, especially of punishment or injury; hostility toward the love object; and conflicting loves, particularly parental and homosexual fixations."

Dr. Huhner responded by dismissing psychoanalysis's claim that impotence is psychological in 95 percent of the cases as less a scientific fact than a philosophical assertion. Huhner did not rule out the possibility of psychogenic impotence. He argued that urologists can discern such a patient from one with organic disease because they do a medical examination, something a psychoanalyst never does. What would one think, he asked,

if a patient with an undersized penis complained of his inability to perform the sexual act and consulted a physician who, without even looking at that organ, informed him that his condition was purely psychic and due to some unresolved complex from his childhood days? This certainly seems ridiculous...but it is exactly the procedure that is followed daily by psychoanalysts.

Huhner also wrote that, while he was not "doubting the psychoanalyst's findings" regarding the prevalence of unresolved Oedipal issues in impotent men, he doubted their methodology in asserting it.

Just as in other branches of medical science, a control should be established to determine the possible presence of such an unresolved Oedipal complex in men who are not impotent....In any other branch of medical experimentation, such a system of control would be the obvious rule.

On these two points, Huhner was on solid ground. Unfortunately, he weakened his case, from our viewpoint today, by insisting on the reality of the link between masturbation and impotence, and the efficacy of treating that condition with jolts of electric current to the penis. (It goes without saying, of course, that he was wrong on both counts.) Equally distressing to contemporary eyes is Huhner's qualified endorsement of the "clinical observations of Stanley," the San Quentin prison doctor, "and Voronoff," Mr. Monkey Gland -- each of whom, Huhner wrote, had scientifically established the "endocrine action" in erectile physiology.

Both of these operators have had [temporary] success in producing sexual desire and erection in impotent persons....And yet, in the face of all these modern observations on the influence of sex hormone, psychoanalysts still believe that everything sexual comes from the brain, and simply ignore the fact that we have been endowed with sexual organs as well as brains.

The fact that a scientist as serious as Dr. Huhner wrote these words in 1936, several years after the Frenchman Henri Velu proved that testicle grafts were "une grande illusion," is troubling. It is also one more reason why urologists lost the early battle for therapeutic control of erectile functioning to psychotherapists and, for several years after the 1970 publication of Human Sexual Inadequacy, by Dr. William H. Masters and Virginia E. Johnson, to sex therapists. Urologists would not, however, lose the war.

A real war -- World War II -- put them on the path to victory. In 1944 the American Review of Soviet Medicine translated an article that appeared in Russian the previous year. "The use of new weapons in the present war has resulted in...wounds which were unknown during World War I," A. P. Frumkin wrote. "The rapid fire of automatic weapons and mine and bomb explosions, with their spray of fragments, have [caused]...the destruction of whole organs. It is not surprising, therefore, that a complete loss of the external genitalia is a frequent occurrence."

In "Reconstruction of the Male Genitalia," Dr. Frumkin offered an extreme solution to an extreme problem. He removed a section of the patient's rib, then made two parallel incisions into the patient's abdominal wall. The flap of skin between those incisions was pulled up, then curved inward into a tube, in which the rib cartilage was inserted. This "tube flap," with the rib inside, was then sewed shut. The resulting product, Frumkin wrote, resembled "a suitcase handle." After a healing period of several weeks, this handle was carefully removed from the patient's midsection and even more carefully attached to whatever remained of his penis. A new urinary canal, made of scrotum skin, was sewed to the outside of the reconstructed penis, running along the bottom. (Frumkin's article included a photograph of a reconstructed patient urinating into a glass beaker.)

Though it may sound freakish to a nonscientist, it is not surprising that Dr. Frumkin experimented with a rib bone. Most mammals, including many of our primate cousins, are born with a bone in the penis called the baculum or os penis. The "little stick" of the fox was described by Aristotle twenty-four hundred years ago. Much more recently the British zoologist W. R. Bett noted that "in the whale [the baculum] measures 2 metres in length and 40 cm. in circumference at the base, and in the walrus it is 55 cm. long." When male otters fight, they have been known to bite an opponent's penis, snapping the bone inside in two. Anyone desiring more information on this subject would do well to visit the lcelandic Phallological Museum in Reykjavík, where more than eighty penis baculae -- from sixteen varieties of land mammals, twelve different whale species, seven types of seal and walrus, and one rogue polar bear -- are preserved and displayed on wall plaques.

Because of examples like this from the animal kingdom, the idea of a penile bone implant in humans made some biological sense. Even so, the results were disappointing. Most bent noticeably within eighteen months; later, nearly all were absorbed into the recipient's body. These problems led urologists to experiment with artificial materials. This research would mark the first major step forward in the medicalization of the erection.

In 1948 Dr. Willard E. Goodwin of the University of California at Los Angeles became the first surgeon to use a synthetic substance to make a baculum in a human. He replaced a patient's bent rib cartilage implant with a single rigid acrylic rod. Not long afterward, however, he had to remove it because of complications. In 1973 Drs. Michael P. Small and Hernan M. Carrion of the University of Miami invented the first device made of paired sponge-filled silicone rods. These flexible, semirigid rods were inserted alongside the corpora cavernosa -- the two spongy bodies that fill with blood inside a normally functioning penis -- and underneath the tunica albuginea, the membrane encasing those bodies. This created a more "natural" appearance than any single-rod implant. Well, maybe "super-natural" is a better term. The Small-Carrion implant did not leave the patient's penis in a constant state of elevation, but it did leave him in a state of perpetual expansion. Some patients, but not all, found this embarrassing.

A solution for that predicament was devised later that same year by F. Brantley Scott of the University of Minnesota, who led a team that created the first inflatable prosthesis. This device, which also used silicone rods, was manipulated up and down by a small pump placed inside the scrotum. Nearly all prostheses in use today are updated versions of Dr. Scott's design, manufactured by American Medical Systems or Mentor, Inc.

Six years before Scott's breakthrough, however, Dr. Robert O. Pearman, a private practitioner in Encino, California, had invented a single-rod silicone implant, which he placed atop and in between the corpora cavernosa and underneath the tunica, a position that caused his patients to complain of pain. Even so, Pearman was a major force in the medicalization of erections -- not for his faulty technique, which he soon abandoned, but for the definition of erectile dysfunction he published in the Journal of Urology.

Pearman defined ED as the "loss of ability to produce and maintain a functional erection due to pathology of the nervous or vascular system, or to deformation or loss of the penis." He did not mention psychological causes at all. This declaration encouraged other urologists to believe what they were already seeing with their own eyes. "Anyone doing implants could see the penile tissue of an impotent man was scarred," says Dr. Arnold Melman, coeditor of the International Journal of Impotence Research. "How could you explain that psychologically?"

Another prolific researcher, Dr. Irwin Goldstein of Boston University, pays homage to Pearman as well. But for Goldstein the big breakthrough was made by Scott's inflatable prosthesis. "Finally we had a therapy that produced reliable, lifelike erections. Before we had nothing to offer, so we left the field to psychiatrists." Most doctors are "acceptors," Goldstein says. "If they read impotence is ninety-five per cent psychological, they accept it." Not Goldstein. "My undergraduate training was in engineering. Engineers do not accept things. They take working machines apart and try to make them work better." The subcutaneous pump in Scott's prosthesis was an inspiration to Goldstein and like-minded urologists "It reminded us that the penis is like a tire. An erection must be pumped up -- with blood instead of air, of course. And when it goes flat, just like with a tire, you have to look for a leak or check out the pump."

In the 1970s the Czech surgeon Vaclav Michal did autopsies on male diabetics, many of whom were impotent when alive. Nearly all, he discovered, had a pump problem -- blocked cavernosal arteries. In "Arterial Disease as a Cause of Impotence," Michal asserted that ED is often the result of this insufficiency. Michal experimented with revascularization procedures on live diabetics to surgically enhance their arterial blood supply, getting good results. In 1978 Dr. Adrian Zorgniotti summoned urologists from Europe and the United States to a conference in New York to discuss Michal's work. "That meeting was a turning point," says Dr. Gorm Wagner of the University of Copenhagen, who was there. "It changed forever the old, erroneous way of thinking of impotence as exclusively a psychogenic problem." Another meeting was held in 1980 in Monaco and, in 1982, in Copenhagen, where participants agreed to exchange scientific information every two years at a World Meeting on Impotence and formalized their organization as the International Society for Impotence Research, the first group of its kind in the world.

In 1981 Michal taught his revascularization procedure to Irwin Goldstein, who became an enthusiastic supporter. Two years later Giles Brindley gave the most startling scientific presentation in medical history -- and in so doing not only launched the erection industry but, even more important, helped scientists to finally understand the mysterious hemodynamic process that makes an erection possible.

Brindley would have to share credit for the second feat with another European. In October 1982, the French surgeon Ronald Virag published a short paper that, in truth, not many urologists noticed at the time. This was several months before Brindley's display in Las Vegas -- something everyone in attendance noticed. While doing a routine surgical procedure at his Parisian clinic, Dr. Virag mistakenly injected papaverine, a chemical that causes body tissues to relax, into an artery leading into his patient's penis, rather than his intended target, another artery nearby. Much to Virag's surprise, his patient, still under anesthesia, responded with an erection that lasted more than two hours.

Virag later tried to duplicate this result in thirty impotent men -- awake, this time -- and was successful. His paper, published in Lancet, was titled "Intracavernous Injection of Papaverine for Erectile Failure." Brindley bared his results in Las Vegas the following spring. Later Brindley would publish "Pilot Experiments on the Actions of Drugs Injected into the Human Corpora Cavernosum Penis." This paper reported on thirty-three injections resulting in erections lasting between several seconds and forty-four hours. A close reading reveals that Brindley did all the experiments on himself.

Before Virag's and Brindley's experiments, the picture urologists had of erectile functioning was still a little fuzzy. "There was a taboo against studying male sexual biology in detail," Goldstein says. "If you studied the heart everyone applauded. But the penis? People thought you were a pervert." Still, urologists had poked around enough to know most of the basics. They knew, for instance, that neurological signals caused the organ to fill with blood. They knew about the cavernosal arteries bringing that blood in and the smaller arterioles branching out into the surrounding corpora cavernosa, the two spongy bodies that expanded once the blood got there. They knew the corpora were composed of smooth-muscle tissue, thin sheets that line blood vessels and most of the hollow organs of the body. Inside the corpora they saw this smooth muscle formed a meshwork of linked spaces called sinusoids. They also knew the corpora were encased by a thin but tough membrane called the tunica albuginea.

What they did not really understand was the most important event in the process -- the mechanism that enabled the penis to trap the blood once it came surging in. Virag's and Brindley's experiments confirmed what some scientists already suspected: the importance of smooth-muscle relaxation. Papaverine, which Virag used, and phenoxybenzamine, the drug injected by Brindley in Las Vegas, were both powerful smooth-muscle relaxants. When injected in the penis, each mimicked the body's own erectile methodology and thus gave urologists a view -- a pharmacological magnifying glass -- into the penis's inner workings.

"We learned that what we learned in medical school [about blood trapping] was wrong," says Dr. Arthur L. Burnett of Johns Hopkins. And had been for a long time. In 1900 a German anatomist named Von Ebner found what he called "pads" lining the arteries bringing blood into the penis. He concluded that those pads enabled the arteries by themselves to regulate blood flow into the penis -- opening up to allow blood in and closing down later to trap that blood and cause an erection. Von Ebner's theory was the prevailing wisdom until 1952, when it was updated by a French urologist named Conti, who said he found shunts, soon called "Conti's polsters," in veins outside the tunica albuginea that carried blood out of the corpora. Conti concluded that these were the mysterious shutdown valves urologists had been searching for for so long. Blood entered the penis, the corpora expanded, and those polsters outside the tunica closed down, Conti said, giving that blood nowhere to go. Result: erection.

Papaverine proved this was not the case at all. "We saw that the key to the trapping of blood is the rapid relaxation of the smooth-muscle tissue in the corpora," Burnett says. "Once that tissue is relaxed, the resistance to blood flowing in is greatly reduced. So the blood comes in, the corpora suck it up like two thirsty sponges, and the tissue expands so quickly that it flattens the exit veins against the tunica."

Those exit veins inside the penis are there for a reason: an erection is not supposed to be a permanent event. It is through those veins that blood leaves the corpora -- after an orgasm, or when a man loses his erection because the telephone on the nightstand starts ringing. That second example of shrinkage occurs because the ringing startles the man, which triggers the release of epinephrine, a smooth-muscle constrictor that causes tissue to tighten. That reaction sends the blood through the suddenly no-longer-flattened exit veins and down the drain, as it were. This is part of the "fight or flight" response sometimes known as an adrenaline rush. It is sexually counterproductive by evolutionary design. All men today are descended from cavemen who successfully got away from a saber-toothed tiger precisely because they were not impeded by an erection. Those who could not lose their erection fast enough were caught and eaten.

When there is smooth-muscle relaxation -- and no saber-toothed tiger -- "the blood that has just entered the penis is trapped, so pressure inside builds by a factor of about ten," Burnett says. Urologists call this process "venous occlusion." We call it getting hard. It doesn't take much blood: less than two ounces, says Dr. James H. Barada, treasurer of the Society for the Study of Impotence. But that is enough to make the typical human penis -- roughly three and a half inches long and one and a quarter inch thick when flaccid -- get two inches longer and more than a half inch thicker, boosting its total volume by around 300 percent. That expansion and rigidity is the difference between a penis with some extra blood, called "tumescent" by urologists, and a bona fide erection. The problem with many impotent men is not that blood is failing to enter the penis; it is that, because the smooth-muscle tissue has not relaxed properly, that blood is draining out immediately after getting there.

Within days of Brindley's demonstration in Las Vegas (and months of Virag's article in Lancet), urologists all over the world were prescribing injection therapy. Papaverine, Virag's drug of choice, was preferred over Brindley's phenoxybenzamine because the latter was shown to be carcinogenic and often caused priapism -- an utterly unfunny condition marked by an erection lasting four hours or more, which can do permanent damage to penile tissue. Reached on the telephone in London, Brindley said that he had suffered "no negative consequences" from his injection experiments in the 1980s, which numbered, he said, "in the hundreds." But then he added: "Well, that's not quite true. I do have a small case of Peyronie's disease," a curvature of the penis, caused by internal scarring, that can cause impotence. "I don't think my experiments are the reason," said Brindley, now professor emeritus of physiology at the University of London. "But who knows?"

Papaverine occasionally causes priapism, too, so urologists experimented with other smooth-muscle relaxants such as prostaglandin E-1, or a mix of papaverine, prostaglandin E-1, and phentolamine as their injection drugs of choice. None of these substances was FDA-approved for use as a medication for ED. They were, however, approved for other uses in the human body, so few doctors were hesitant to prescribe them. This off-label use, as it is known, is common medical practice. In 1995 Pharmacia and Upjohn received FDA approval for the first drug specifically approved for impotence -- Caverject, a synthetic form of prostaglandin E-1, injected into the corpora cavernosa. Two years later Vivus received approval for the same medication delivered by a transurethral pellet. In 1998 both would lose market share to Viagra.

Approved or not, those first-generation erection drugs certainly worked -- in some ways far better than original equipment. A penis injected with a smooth-muscle relaxant could stay hard for hours and remain hard after orgasm, a lure some men found irresistible. Glossy magazines reported on a black market for the drug in Hollywood, where it became a favorite of aging producers "forced" to entertain young starlets. "Girls love the shot," Dr. Uri Peles, a Beverly Hills ED specialist, told me at the 1996 World Meeting on Impotence. "They might not want a hard man, but they want a man hard." What seems funny can, and occasionally has, turned tragic. According to Dr. Goldstein, several Hollywood types have come to his Boston office with serious pathology. "One patient was having an affair with a younger woman. He was perfectly healthy but wanted a little 'performance enhancer.' He injected himself with forty micrograms of prostaglandin -- a proper dose for a man with impotence, but about four times higher than anything he might have easily tolerated." The result, Goldstein said, was "a forty-eight-hour erection. That's like having a tourniquet on down there."

After Brindley and Virag, urologists not only began prescribing smooth-muscle relaxants for at-home use, but injecting them in a hospital or consulting-room setting for research purposes. If medical remedies such as drugs and surgery were the primary products of the new erection industry, the secondary products were expensive tests designed to find the vascular problems requiring those remedies. For much of the 1990s, urologists routinely gauged their patients' erectile functioning by injecting their penises with smooth-muscle relaxants, then measuring the arterial blood flow via ultrasonography, a method that sends sound waves into the chemically erected penis and then converts the returning sound waves into an electronic image on a monitor. If the flow after an injection is low, the doctors said, it indicated an arterial-supply problem that possibly required surgery.

Another, even more extensive and expensive, test is called dynamic infusion cavernosometry and cavernosography -- or DICC (pronounced "dick"), for short. Irwin Goldstein, a champion of this procedure, told me, "Just like with a tire, you can't always find the leak when it's flat. You have to inflate it and put it under water. We inflate the penis with drugs, then we do our version of the water test."

In the first part of a DICC study, Goldstein records the blood-pressure response inside the corpora after the injection of smooth-muscle relaxers. The goal is to see how closely that penile pressure approaches the mean pressure of an artery in the patient's arm. Next he tests the patient's blood-trapping mechanism by injecting saline solution into the corpora until the patient's penis reaches a defined pressure. Goldstein then charts how fast the erection pressure drops after the infusion is stopped. In a normal man, the saline flow needed to maintain pressure, and the resulting pressure drop after the flow is terminated, are both small. In a man with ED they are quite large. In the third phase of the DICC study, ultrasound charts the blood pressure of the penile arteries. Finally, an X-ray is taken of the erect penis, providing the physician with additional anatomical data.

By the late 1990s, however, there was a feeling such tests were neither essential nor very accurate. "I haven't done a DICC in years," says Dr. Barada. "They make some sense in an academic setting, where you're collecting data and trying to stratify patients" -- factors that do apply to Goldstein's work, by the way. "But I've been to Boston," Barada says, "and it seems to me that if you're secretly hoping to find pathology that setting will probably deliver it. The patient is lying on a cold hard table. People he doesn't know are walking in and out. There's no soundproofing. Screens are flashing nearby. Doctors are ostensibly checking for normal smooth-muscle relaxation in a totally abnormal situation."

Viagra would render this debate moot. Nowadays urologists do little or no tests on ED patients. They take a medical history, then, in most cases, write a prescription. "Once I determine [from an interview that] the patient is a good Viagra candidate," says San Francisco urologist Ira Sharlip, president of the Society for the Study of Impotence, "I say, 'You probably have an organic disease. Do you need to know that it's sixty-five percent arterial and thirty-five percent venous or vice versa? Or are you interested in taking a pill that will probably give you an erection adequate for penetration?' You can guess the answer."

This is why millions of Viagra users, whether they know it or not, are taking part in one of the largest unsupervised (or barely supervised) medical trials in history. Only a few thousand men took Viagra in the trials run by Pfizer in the mid-1990s. In the months after the drug's approval, in March 1998, that number jumped more than a thousandfold -- with little or no tests to determine whether those patients had a genuine erectile disease or possibly dangerous preexisting conditions.

This seems to have had fatal consequences. In November 1998, Pfizer agreed to augment and expand the warning label included with every Viagra bottle alerting users and physicians to the danger of mixing Viagra with heart medications containing nitrates. Between late March and mid-November 1998, more than one hundred Americans died within hours or days of taking Viagra. Half those deaths, the FDA reported, were associated with heart attacks. (The reason for many of the other fatalities could not be conclusively determined.) According to a World Health Organization report, none of the patients in Pfizer's clinical trials for Viagra had suffered a heart attack, stroke, or life-threatening arrhythmia within six months of taking the drug. It appears that some Americans who had may have been prescribed and taken Viagra -- incurring the most permanent side effect of them all.

Pfizer and the urological establishment insist that Viagra is safe for men not taking nitrates. And it appears they are right. For now. But the financial ties between urologists and drug companies make some critics worry that a doctor's ability to speak the unvarnished truth has been compromised. Manufacturers pay urologists in the area of $5,000 per patient enrolled in a clinical trial for an impotence medication. Some, like Irwin Goldstein, have hundreds of patients taking part in different trials at once. Many urologists own stock in the companies whose products they test. Others serve as paid consultants to those firms, in some cases signing nondisclosure agreements that prevent them from divulging data that might conflict with that company's marketing statements about new drugs. "It isn't possible to go to anybody in this field right now for a neutral opinion," Dr. Jeremy Heaton told Fortune magazine recently. (Heaton, a respected impotence researcher at Queen's University in Kingston, Ontario, is himself a paid adviser to a drug company trying to bring a new erectile medication to market.)

This is not to imply that Drs. Goldstein or Heaton, or any other ED researcher, entered the field just to get rich. They could earn far more if they left academic medicine altogether, closed down their expensive laboratories, and ran a purely private practice. Nor is anyone suggesting they are shills for Fortune 500 companies hoping to get into the Fortune 5, or that they would ignore a dangerous side effect of a drug they were being paid to test. Helping patients -- whether by drugs, surgery, or a sympathetic ear -- is, without question, the top priority of just about every physician in the ED field. (Goldstein's attentive manner with patients, which I have witnessed, could be a model for the entire medical profession.) Indeed, it is because of the missionary zeal of Goldstein, Arnold Melman, and others like them that drug companies were awakened, often against their will, to the fact that erectile dysfunction is a serious condition with consequences meriting serious attention.

But there can be financial consequences to breaking ranks with the erection industry. Dr. Ronald Lewis of the Medical College of Georgia was cut loose by a drug company testing an impotence medication after he expressed doubts about its efficacy. "They read my skepticism and figured I wouldn't be out there pushing," Lewis says. "So I was out." Nothing like this happened during the Viagra trials, that we know of, and Viagra's problems for the approximately 9 million American men taking nitrates is now a well-disseminated fact. But Maxim, Details, and other slick magazines aimed at young, sexually active men -- a group decades away from serious cardiac worries -- report that Viagra has become a drug of choice for their club-crawling audience, often taken in conjunction with Ecstasy, a party drug that enhances sexual desire but can inhibit sexual performance. Viagra, because it solves the latter problem -- without the priapism risk of injectable drugs -- has become de rigeur among the party-hearty set. But the long-term effects of Viagra on this nonprescribed, nonclinically tested population are unknown.

Several weeks after Viagra's approval, Dr. Robert Kolodny of the Behavioral Medicine Institute in New Canaan, Connecticut, a former partner of the famous sex researchers William Masters and Virginia Johnson, told the New York Times, "Whenever a new drug is introduced, pharmaceutical companies tout it as extraordinarily effective and without side effects." But "years later...side effects emerge that were not previously seen. There may be interactions between Viagra and other drugs....Men may use it at higher doses....And it will undoubtedly be used by a wide range of people, not all of whom are suitable or adequately screened beforehand." Kolodny's words proved to be prescient. A different set of questions was raised by San Francisco attorney Michael Risher, legal adviser for the Lindesmith Center, a think tank on drug policy. "There are striking similarities between the recreational use of Viagra and, say, anabolic steroids and tranquilizers," he wrote. "It is legally considered drug abuse if a man ingests steroids simply to look virile. So why isn't it illegal to take a pill to become virile?"

Not everyone was alarmed by Viagra's appeal to John Doe, or its risks. "Feminism has emasculated the American male," Penthouse founder Bob Guccione told a Time reporter. "And that emasculation has led to physical problems. This pill will take the pressure off men...and undercut the feminist agenda." Hugh Hefner gave similar interviews praising the drug. In most of them he was accompanied by three statuesque women, each young enough to be his granddaughter, that he was said to be dating simultaneously.

In September 2000, Dr. Milton Lakin of the Cleveland Clinic welcomed several hundred scientists, and a smaller number of science reporters, to his home city for the Fall 2000 Research Meeting of the Society for the Study of Impotence (SSI). He reminded them that several decades ago he had predicted that people would be having sex on the moon before there would be an impotence pill that actually worked. He then invited the audience to listen to a few "can't miss" stock tips. When the laughter ended, Lakin got serious. "The ability of researchers, many of them in this room, to devise new treatment options for erectile dysfunction is one of the great achievements of modern medicine," he said. Clearly, the treatment that has astounded Lakin and the media the most -- Viagra -- never would have been found had it not been for the research that followed the groundbreaking work of Brindley and Virag nearly two decades earlier.

Once urologists grasped the importance of smooth-muscle relaxation, they focused on identifying the primary neurotransmitter that initiated that process. They had a good lead. Three scientists working independently, Robert F. Furchgott, Louis J. Ignarro, and Ferid Murad, had already established the role of nitric oxide in relaxing smooth-muscle cells in the vascular system. This led urologists to examine the role of that molecule in the penis, where they confirmed the findings of those three scientists. (In 1998 Furchgott, Ignarro, and Murad were awarded the Nobel Prize for medicine.)

The link between nitric-oxide-signaled erections and Viagra (sildenafil citrate) was discovered by accident. In the mid-1980s, Pfizer developed a new compound that it hoped would be an effective drug for angina pectoris -- severe chest pain caused by deficient oxygenation of the heart muscles. This drug was sildenafil citrate, which inhibited the production of phosphodiesterase-5, an enzyme also known as PDE-5. Studies on sildenafil's effectiveness, overseen by Dr. Ian H. Osterloh, began in England in 1990 and two years later produced results both disappointing and intriguing: males taking sildenafil reported their angina was as bad as ever, but there was this not unwelcome side effect....

At first Osterloh and his team though it was a fluke. But recent papers on the function of nitric oxide made them realize they might have stumbled onto something important. (This gets a little technical, but bear with me.) Scientists now understood that the presence of nitric oxide inside the corpora cavernosa caused an increase in the levels of another substance called cyclic guanosine monophosphate (cGMP). It was cGMP that directly relaxed the smooth-muscle tissue inside the corpora, thereby making an erection possible.

But scientists also noticed there was another substance in the corpora -- PDE-5 -- that reversed this process by breaking down the cGMP. Because it is a PDE-5 inhibitor, Viagra prevented that from happening. It did not so much create the erection as it stopped that erection from wilting. Just like those pesky exit veins, PDE-5 is in the penis for a good reason. The organ's default setting, as it must be in a civilized world, is flaccidity. Considering the sexual stimulation that exists in places one does not always expect to find it -- the elevator, for instance -- it is a good thing that the erection-inhibitor is there. Except when a man is having sex, when the signals to relax and expand in the corpora cavernosa overwhelm those to tense up and constrict. (At least they do in a normally functioning man.) "The beauty of Viagra," says Dr. Andrew R. McCullough, a urologist at New York University, "is that it enhances a man's natural response to sexual stimulation by diminishing its equally natural inhibiting process." This cross talk between signals urging a penis to become erect, and others demanding it go soft, creates a constant state of static inside every man. Not only does a penis have a mind of its own, it has two minds.

The approval of Viagra, the first oral medication for ED, on March 27, 1998, marked the biggest moment yet in the erection industry. Along with enhancing the sexual performance of millions of men, that industry and the research that produced it accomplished something almost equally dramatic -- making urologists even more in awe of the penis than they already were. "The penis is an anatomical marvel," says Dr. Arthur L. Burnett. "It can change size and shape, become rigid and flaccid, and expel semen and urine through the same collapsible tube. What other organ goes through so many changes or has so many functions? It is clearly one of the most cleverly designed organs in the body."

That cleverness begins on the outside and moves in. The skin of the penis shaft is thinner, looser, and more elastic than just about any patch on the human body. The glans is hairless, putting it in direct contact with everything it touches. A 1986 study in the journal Brain Research found sensory receptors distinctive to the penis in the glans, the corona (the fleshy lip on the outer edge of the glans), and the frenulum, the small, wrinkly band of skin just below the glans. All three of these areas enlarge when aroused, creating more surface area -- and more erotic sensation.

The result is a unique neurological hot spot, one more about quality than quantity. Sensitivity is measured by density of nerves, says Dr. Claire C. Yang, coauthor of "Innervation of the Human Glans Penis" (Journal of Urology), and one of medicine's rarest breeds, a female neurourologist. Nerve density is pretty good in the penis, Yang says, but it is far greater in the face and hands and there are larger areas in the brain working to process signals from those places. This makes sense, considering we are descended from apes that lived on all fours and spent much of the day sniffing for food in the rain forest. But no one is suggesting that signals from, say, the palm are more vivid than those from the penis. Messages from the male member are so powerful, in fact, that Dr. Yang thinks they can do something no other body part can: temporarily alter the brain itself. "Stimulation from the penis seems to expand and enhance the brain's ability to process that stimulation," she says. Yang, a researcher at the University of Washington, has not proved this yet, but she's working on it.

The urethra, the penis's internal transport tube, runs from the meatus (the hole) to the bladder, a distance of about six inches -- nearly half of that inside the body -- and stretches when the organ is erect. It is surrounded by the corpus spongiosum. Together, they lie beneath two larger, even spongier bodies, the corpora cavernosa, which sit above them to the left and right; all of these bodies are encased by a lining called the tunica albuginea. The corpora cavernosa, which fill with blood when one has an erection, extend down the shaft into the body, where ligaments tie them to the pubic bone. These ligaments are severed in patients undergoing penile-extension surgery. Afterward gravity pulls the penis down, making it "longer" -- and a lot wobblier, which is why most urologists neither recommend nor perform the procedure.

The tunica albuginea, the lining that surrounds the penis's internal workings, is another structural marvel -- up to a point. "It is about as thick as a magazine cover," says Dr. Ajay Nehra of the Mayo Clinic, in Rochester, Minnesota. "It's very strong, but not very flexible," factors that enhance erectile firmness but create a potential for a serious injury called penile fracture. Actually, this is more like a muscle tear than a cracked bone. The cause is usually overly athletic intercourse, typically with the woman on top. Such fractures are rare, and if treated within twenty-four hours the tunica can usually be repaired. If not, injection drugs help in most cases. Major tears may require the insertion of a penile prosthesis.

Of ejaculation and orgasm, only the first takes place in the penis. The second occurs in the brain. But ejaculation is, of course, triggered by the brain, which receives pleasurable stimulation from the penis -- sometimes only for a minute or two, as women well know -- until it passes a certain threshold. As the brain erupts into orgasm, it still has the presence of mind to send signals to the genitalia. Sperm cells have already been produced by the testes and are in the epididymis. Another tube, the vas deferens, connects the epididymis to the urethra and transports the sperm there. (This is why ligating those tubes, in a vasectomy, makes a man sterile.) Glands called seminal vesicles meet the vas just before they enter the urethra. These provide fructose and other secretions required for the sperm to exist outside the body. The prostate, which surrounds the base of the urethra like a donut, also provides chemicals enabling the sperm to complete their trip.

At "show time," sperm are moved from the epididymis, through the vas, and deposited at the bottom of the urethra, near the prostate. At the same moment, the seminal vesicles and prostate contract, emitting their fluids. These secretions mix together, then are forced out by a series of convulsions by the bulbourethral muscle, which surrounds the urethra, near the bottom. (Imagine holding a sausage with the casing cut open at one end in your fist, then squeezing.) "Sperm make a journey the equivalent of a marathon in two to five seconds," says Dr. Abraham Morgentaler, a urologist at Harvard Medical School. Is it any wonder men fall asleep so soon after sex?

Ask Leonore Tiefer about that and you will get a different explanation. Tiefer is a psychologist, feminist, sexologist, sex therapist, former newspaper sex columnist, and author of Sex Is Not a Natural Act and Other Essays, a collection published in 1995. (Yes, she thinks about sex a lot.) Tiefer is a serious person, but not so much that she cannot enjoy a good laugh. She just doesn't think the urological takeover of male sexuality -- the "pursuit of the perfect penis," she calls it -- is very funny.

Tiefer opposes that quest for a slew of reasons: Because she thinks it is motivated more by money than medicine. Because it uses shaky evidence to dismiss the interpersonal causes of ED. Because it reduces the mystery of sex to universal standards of nerve sensitivity, smooth-muscle relaxation, and blood flow. Because it proceeds from the idea that creating an erection is the same as creating sexual enlightenment. And because it is not a giant step forward in the eternal march of scientific progress, as urologists claim, but a social construction of the late twentieth century -- a reaction against feminism, bolstered by the belief of male Baby Boomers that they are entitled to be erect forever.

"Erections are presented not only as the 'goal,'" she says, "but as knowable in and of themselves, unattached to a person or relationship." Tiefer is not a huge fan of Masters and Johnson, least of all for the way they defined intercourse in Human Sexual Inadequacy as "a matter of vascocongestion and myotonia" (that is, the engorgement of tissue with blood and involuntary muscle contractions). But at least Masters and Johnson were smart enough to realize the patient in sexual-dysfunction cases is the couple. "Now," Tiefer says, "the only patient is the penis."

In her view, this has transformed women from participants in intercourse to an audience. "Of course I know many women like harder and longer-lasting erections. But some of these women will be forced to deal with those chemically induced erections whether they're in the mood or not. And the medical establishment doesn't even ponder that possibility." That same establishment, she says, also absolves men from responsibility for their sexual performance. "Urologists are men. They know men don't want to talk about their relationships, or make any embarrassing disclosures. So the urologist tells his patient: 'You don't have to, because your sexual problem isn't your fault.

You don't have a technique problem or a relationship problem. You have a vascular problem in your penis. And I can fix that.'" This medical view of ED is based on a misunderstanding of what sex is -- and what it is not, Tiefer says. "Sex isn't a natural act, like breathing. It's not a universal, either. Sex in Peru is not the same as sex in Peoria. Sex is a talent, like dancing. Some people are good at it, some aren't. But most people can learn how to get better. That's how sex therapy can help in a way drugs can never help."

These are provocative opinions, but not ones you are likely to hear at the Society for the Study of Impotence, or any other group dominated by urologists. Tiefer's assertion that those specialists have achieved a hostile takeover, winning preeminence in ED based on weak epidemiological evidence, has some merit. The survey usually cited by urologists to support their hegemony is the Massachusetts Male Aging Study, coauthored by the ubiquitous Dr. Goldstein and a staff from the New England Research Institutes. Between 1987 and 1989, the MMAS gave medical checkups to 1,290 men between forty and seventy years of age. The men were also given psychological tests and assayed for lifestyle issues such as smoking, diet, and exercise. Then a self-administered sexual activity questionnaire was used to rate erectile potency. The final report not only confirmed the vascular etiology of nearly all cases of ED but made some startling conclusions about the prevalence of that disease. According to the MMAS the incidence of total impotence in men tripled, from 5 to 15 percent, between ages forty to seventy. That got a lot of press. But even more newsworthy was the assertion that a majority of men over forty had some form of impotence. This led the National Institutes of Health to project that 30 million Americans have erectile dysfunction, three times higher than any previous number.

Those numbers were shaped by the questions. One posed by the MMAS was, "How satisfied are you with your sex life?" -- in effect, rating anyone who did not answer "totally" as having minimal erectile dysfunction. Before, ED was defined as "the persistent failure to develop and maintain erections of sufficient rigidity for penetrative sexual intercourse." (Italics added.) After the MMAS even a rare visit from Mr. Softee was deemed a disease state. "Why the obsession with rigidity?" Tiefer asks. "A rock-hard erection isn't even necessary for satisfying sex."

Comments like that lead urologists to say Tiefer knows less about men and sex than she thinks she does. One who knows Tiefer's views extremely well is Arnold Melman, who hired her to screen ED patients at Montefiore Medical Center in the Bronx, New York, where he is chief of urology. "I brought her in because I have great respect for her intelligence and skills as a psychologist," Melman says. "Plus, I liked having her as a counterweight." For a while, anyway. In the late 1990s, Melman and Tiefer went their separate ways: he stayed, she left.

"Anyone who doesn't think a man needs a firm erection doesn't understand men," says Melman. "I see a lot of municipal workers in my practice. We have a contract with a [New York] city health plan. These are tough, physical guys -- bus drivers, subway motormen, laborers, etcetera. I've gotten used to seeing them cry in my office. They cry twice, in fact: first, when they tell me they can't get an erection. And second, after we treat them, when they tell me they can. And, no matter what Leonore says, I haven't met one wife who was unhappy with that change.

"Where I agree with Leonore is that there are men with relationship issues, and just giving them an erection isn't going to make those issues go away. That's why we screen patients psychologically and make appropriate referrals. But I have my doubts about sex therapy. I've checked on the results for the people we sent there. Basically, one person in forty had a good result. Once I was asked to guest-edit the Journal of Sex and Marital Therapy. I wanted to analyze the outcomes of all the ED therapies, medical and otherwise. I asked several sex therapists to present data, including Helen Singer Kaplan, who had the largest practice in the world. They all refused. I'm not saying they're charlatans. But they're not willing to publish their data. Urologists are, because our approach works. Patients want results -- an erection -- and they want it fast. That's human nature. If not human nature, it's certainly male nature."

And now it is even easier for doctors to respond to that nature. (Or at least quicker.) The sex questionnaire in the MMAS had nine questions. Now Pfizer salesmen are leaving a questionnaire they call the "Sexual Health Inventory for Men" in doctors' waiting rooms that has only five questions. Anyone whose answers total less than twenty-two out of twenty-five gets the message, "You may want to speak to your doctor." In Pfizer's vision of ED any score lower than the 88th percentile is a failing grade and grounds for a Viagra prescription. Even some urologists blanch at this. "There is a difference between erectile dysfunction, which is a real disease, and erectile dysphoria, which is vague sense of dissatisfaction," says James H. Barada. "I worry the line is getting blurred." Tiefer could not agree more.

But one of Tiefer's admirers, Kinsey Institute director John Bancroft, a British psychiatrist with forty years' experience in sexual medicine, would remind her there was no hard evidence to back the claim of psychotherapists that ED was almost entirely psychogenic, either. "We've gone from one myth to another," Bancroft told me at the 2000 SSI meeting. "Scientists aren't supposed to deal with myths, and they try not to, but they occasionally accept ones that are convenient. When urologists had no treatments for erectile dysfunction, they were ready to believe it was always a psychological problem. Once they had treatments, they were ready to believe the 'it's always vascular' myth. This does not make urologists evil," Bancroft said. "Practical maybe, but not evil."

If urologists are practical, drug companies are the black belts of practicality. As this is written, Pfizer is testing a Viagra inhaler on animals, hoping to deliver this faster delivery system to humans later on. (A Viagra pill can take an hour to work.) After the bad press that followed Viagra's links to fatal coronaries, Pfizer pumped more than $50 million into consumer outreach, sponsoring a car on the NASCAR auto-racing circuit, and creating a new marketing campaign aimed at a younger clientele. In Fall 2000, American TV watchers began to see advertisements featuring a handsome male in his forties seemingly preening for a date as a bluesy voiceover growled, "I'm ready -- ready as anybody can be." The man then ran down the stairs, hopped into his car, and drove to a doctor for a free sample of Viagra. These promotions are expensive, but worth it: In February 2000, Forbes reported Pfizer's profit margin on Viagra at 90 percent and predicted annual sales would soon top $1 billion. The campaigns have also had an evaporating effect on the public's memory: When is the last time you heard anyone mention a Viagra death?

Pfizer's jackpot has lured others into the market. Bayer, the aspirin company, is testing its own PDE-5 inhibitor, Vardenafil. So is a partnership between Eli Lilly and ICOS for a pill called Cialis. What makes these pills potentially the most groundbreaking products yet in the erection industry is that the half-life -- the time it takes for a drug to lose half its potency -- for each is about four times greater than that of Viagra, which is four hours. This means a man could take such a pill at noon and be fully cocked and loaded for sex for the rest of the day. A paper presented at the 2000 SSI meeting in Cleveland reported on volunteers in Europe who took Cialis once a day every day and had dramatically improved erections, without untoward side effects. This report was met with elation. Several doctors in the audience called it the urological version of putting a man on the moon.

Bancroft was intrigued by the Cialis report but questioned the drug companies' candor. "I don't think these medications are the simple erection aids their manufacturers say they are," he said. "Pfizer's position is that Viagra has no effect without sexual stimulation. They say this because their attorneys do not want the drug to be known as something that enhances sexual desire. If Viagra were an aphrodisiac, it would become an even bigger seller than it already is, but it would also create huge legal problems. A rapist could say, 'It wasn't me. It was the Viagra.' Now that companies are testing drugs that last nearly twenty-four hours, this issue could move from potential to actual. From my own clinical experience," Bancroft said, "I suspect Viagra does have certain properties of an aphrodisiac -- or, more accurately, has the power to enhance one's libido without external stimulation. Mental stimulation seems to be enough."

Bancroft is not the only one wondering about such issues. Pfizer hired Arthur Caplan, a bioethicist at the University of Pennsylvania and frequent talking head on Nightline, to grill them with hypotheticals. How will Pfizer respond when a rapist uses Viagra? "It's out of Pfizer's control," Caplan counseled them to say. The company also discussed the drug with the Vatican, assuring the Pope's science advisers that Viagra is not an aphrodisiac. Whether that is true or not, one thing is certain: Some heavy hitters are betting the financial future for drugs like Viagra, Cialis, and Vardenafil is bright indeed. One guy who knows a little about grabbing market share -- Bill Gates -- bought a 13 percent stake in ICOS, the company that created Cialis in its Bothell, Washington laboratory.

Before Gates starts counting his next billion, however, he should know this: Another rich nonurologist, Ross Perot, was an early investor in a Texas erection-industry firm, Zonagen, which partnered up with Schering-Plough to bring oral phentolamine (trade name: Vasomax) to market as a pill competing with Viagra. Unfortunately for Zonagen's investors, the FDA sent Zonagen a nonapproval letter in May 1999, because of "brown fat proliferations" found in rats who were given the drug. Later, an amended application was put on "clinical hold" because of the same concerns. In October 2000, the firm finally agreed to finance a new study to address those issues. Zonagen's stock, which was selling at $40 per share in late 1997, was at less than $4 when the firm made that announcement.

Another, even larger, erection-industry player got burned in 2000. After an investment of many millions of dollars, TAP, a joint venture of Abbott Laboratories in Illinois and Takeda Industries of Japan, withdrew its new-drug application for Uprima, a lozenge of apomorphine placed under the tongue. (Apomorphine is not related to morphine.) Rather than affecting the penis directly, as PDE-5 inhibitors and injectable drugs do, Uprima works on the brain, where it mimics dopamine, one of the chemicals nerve cells use to communicate with one another. Essentially, Uprima empowers the brain to send stronger signals down through the spinal cord and into the penis, where those signals help build an erection.

Because it dissolves under the tongue, Uprima can work in twenty minutes or less. This produced upbeat press coverage and major interest from investors; both expected Uprima to take a major chunk out of Viagra's market share. Unfortunately for TAP, Uprima also produced side effects, ranging from nausea to loss of consciousness. In fact, nausea was once considered one of apomorphine's beneficial side effects. According to neuroscientist Simon LeVay, the drug was used thirty years ago in aversion therapy aimed at "curing" male homosexuals. The patient was injected with 5 mg of apomorphine, then shown photos of attractive naked men. "With repeated treatments," LeVay wrote in Nerve.com, "the patient was supposed to develop an unconscious link between naked men and nausea, and same-sex desires would be extinguished."

It's not certain whether TAP or the FDA knew about Uprima's "secret history," as LeVay calls it. But it appears the chemical's tendency to cause fainting was enough to doom the drug in the United States. When the FDA learned that one patient in TAP's trial, after taking Uprima, fainted while driving his car, and another passed out in his doctor's office, fracturing his skull on the floor, TAP withdrew its application, fearing a rejection.

Uprima's rise and fall sheds some light on the dark side of the cozy relationship between doctors and drug companies. According to one urologist who accepted a fee from TAP to take part in a mock approval hearing for the drug before it was submitted to the FDA, the company should have seen there was trouble ahead. Several doctors at that "practice" event were not impressed with Uprima's efficacy rate which, at 54 percent, was significantly lower than that of Viagra (approaching 80 percent). "A few panelists said, 'This is a lousy drug, with annoying side effects, we shouldn't approve it,'" said the urologist, who asked not to be identified. "But, in the end, the panel voted to 'approve' it anyway, basically saying, 'Why not?'" The fact that TAP had been spreading quite a bit of money around for research costs and consulting fees may have had something to do with that decision -- which was not legally binding. Or maybe not. One would like to think such things have nothing to do with the process at all.

Urologists welcome pharmaceutical breakthroughs that do get FDA approval -- even pills you do not need a urologist to get, like Viagra -- because they know each advance brings in patients for services you do need a urologist to get. Viagra does not work for everyone. One well-listened-to paper at the recent SSI meeting was titled "Viagra Failures." Treating such patients has become something of a specialty for the paper's author, Dr. Gregory A. Broderick, who reported that most of those nonresponders were men over sixty with severe arterial insufficiency. Nearly all of them, he said, chose injection therapy, revascularization, or implant surgery, monitored or performed by him at his Mayo Clinic office in Jacksonville, Florida. Broderick did not mention, nor did he have to, that the Baby Boom generation -- the largest in history -- will turn sixty later this decade. To assess the suitability of patients for such urological treatments, Broderick urged his peers to resume the diagnostic tests most of them abandoned post-Viagra. Interestingly, Broderick's research costs for his paper were partially covered by the manufacturer of one of those diagnostic devices.

This return to the operating room will be profitable for urologists, but what about patients? While there is no doubt that many men with ED have been helped by surgical interventions, it is also undeniable that some have been harmed, and not just in the distant past. In the 1980s, many reputable urologists performed a procedure known as venous ligation, which impeded the blood flow out of the patient's corpora cavernosa by tying off certain veins. The theory was that the patient was losing his erection because of venous leakage, a failure to store blood rather than a failure to fill with it. There was an 80 percent success rate -- at first. Then the bad news started coming in. Erectile problems almost invariably returned. Even worse, the procedure often left the patient with a numbed penis. Forever.

Those and other surgical misadventures prompted John Bancroft to sound an alarm. In 1989 he voiced his concern as a question which doubled as the title of his essay: "Man and His Penis -- A Relationship Under Threat?" As a psychiatrist (a physician trained in anatomy and physiology), Bancroft was less likely than, say, psychologist Leonore Tiefer, who did not get such medical training, to reject the urological approach completely. Even so, he was troubled by the willingness of urologists to ignore the mental aspects of impotence, whether as cause or effect. Treatments such as revascularization, inflatable silicone implants, and penile injections, he said, do not address the problem as much as they "overwhelm and obscure" it with drugs and surgery.

"I have entitled this paper 'Man and His Penis -- A Relationship Under Threat?'" Bancroft wrote, "because I have concluded that the essence of male sexuality rests in the relationship, and associated misunderstandings, that exist between man and this component of his sexual anatomy....

The size of a penis is as much a function of psychological processes as it is anatomy. Often erection endows a situation with a sexuality the owner may not have recognized or be prepared to acknowledge. And how often does the penis resolutely refuse to support its owner in a sexual endeavor, as if to say, "you have no business doing this -- count me out of it?"

Either way, the penis is the most honest organ on a man's body. It tells the truth, Bancroft was reminding his readers, whether its "owner" wants to hear it or not. (The identical conclusion was reached by Gay Talese in Thy Neighbor's Wife, the best-selling book in which Talese did some extremely personal reporting on the Sexual Revolution of the 1960s and '70s.) "Late in my career," Bancroft wrote, "and, it should be added, in my personal life, I have come to recognize the importance of this understanding between a man and his penis, ironically at a time when developments in medical care appear to be rejecting it."

Eleven years after writing those words, Bancroft said he would not retract them, though he wasn't quite as worried as he used to be. "The easy availability of oral medications has pushed surgeons aside for the moment. We're still in the early stages of all this, however, and I certainly do not think urological surgery is about to become obsolete. Most urologists still say, 'Let's concentrate on the penis. No need to think about the man attached to it.' As if you could separate them."

It just might be, however, that the erection industry and the urologists who created it understand the relationship between man and his penis far better than their critics realize. Sure, they are confident in the superiority of their approach. But this arrogance is neither new nor unjustified. It is part of a process that began more than five centuries ago with Leonardo da Vinci and Regnier de Graaf, men who used science and the spirit of experimentation to address difficult questions about sex and masculinity. What once seemed divine or demonic became neither. This process created a new relationship between man and his defining organ. Now the penis is seen as a complex but knowable organic machine. Man is capable of not only understanding Nature, but his own nature -- and altering it. And most men are happy about that.

This is why the urologists who compared Cialis, the once-a-day erection pill now in clinical trials, to putting a man on the moon have not lost their sense of proportion, despite their mixed metaphor. Ending impotence by bringing a small pill to your lips -- my apologies, Commander Armstrong -- is a giant leap for mankind. With it the idea of the penis has made its most dramatic evolution yet, becoming a daily reinflatable tire, with every man just a prescription away from owning the proper pump. And even a urologist can grasp the psychological impact of that.

One ED specialist, Dr. J. Francois Eid of New York, says his practice made him realize that losing potency is like losing a part of one's mind. "I don't mean the patient goes insane," Eid says. "But he definitely loses a part of his identity." It is precisely because a man can hold his manhood in his hand that he needs it to feel strong and capable -- and some would argue this need is now more urgent than ever. This is because technology has rendered nearly all the previous definitions of masculinity obsolete. A man is no longer measured by his physical strength -- his ability to build shelter for his family, fight in hand-to-hand combat, or draw water from a well. Machines do that for him. Muscles are more symbolic than useful. So the erect penis has become the most powerfully symbolic "muscle" of them all.

One of Eid's patients told him his impotence robbed him of everything he valued most: his self-respect, the intimate part of his marriage, his patience with his children, even his sense of humor. "Every time he heard a joke about sex his head would sink into his shoulders," Eid says. "It was like he had cancer of the ego." This phallocentrism, Tiefer and like-minded critics would argue, is less a biological fact than something men learn -- and therefore something they can and should unlearn. It is a social construction, they say, part of a male-centered sexual script written by the culture at large and reinforced by the first sexual act that most males experience: masturbation. The importance of that act in writing an individual's "sexual script," say John H. Gagnon and William Simon, the coiners of that term, cannot be overestimated.

Masturbation "proclaims the male's independence," they wrote in Sexual Conduct. It "focuses male sexual desire in the penis, giving the genitals centrality in the physical and symbolic domains....The capacity for erection is an important sign" -- most men would say the most important sign -- "of masculinity and control."

This concept of sexual script suggests another cinematic metaphor with which to view the erection industry and the ways it has changed man's bond with his penis. The history of that relationship has all the elements of an epic Hollywood film: sex, conflict, mystery, religion, heroes, villains, piles of money, high-tech machinery -- even death. And now, thanks to the erection industry, that relationship has something every film epic needs. An ending.

For that is what you get when you answer the control question. Prior efforts to deal with the "who's in charge?" issue have created the numerous lenses that man has used to examine the most enduring mystery in his life. The history of the penis is the history of its evolution as an idea. Over time the penis has been deified, demonized, secularized, racialized, psychoanalyzed, politicized, and, finally, medicalized by the modern erection industry. Each of these lenses has been an attempt to make intellectual and emotional sense of man's relationship with his defining organ; clearly, some lenses were sharper than others. There is no denying the weighty influence of Augustine and Freud, but it appears the medicalized lens may have the heaviest impact of them all.

We have an ending to our story, but not the end. The bond between man and his penis, fundamentally altered as it is, continues. And while much of its central mystery has been solved, other mysteries remain. The medicalized penis is only two decades old, the era of the erection pill younger still. Both have answered huge questions but raise others. Science has helped men with erectile dysfunction, and a medicalized penis is certainly better than a demonized one, but the long-term effects of PDE-5 inhibitors on the penis have yet to be determined. Might not regular exposure to them cause the body to produce an abnormally high level of PDE-5? (Such a reaction would not be unprecedented, or even unexpected.) And what effect would that have on a man's internal chemistry? Or behavior? The answers will be known later -- maybe too late for some.

On another front, admittedly more metaphysical than medical, some critics worry that the erection industry has replaced an idea of the penis with an anti-idea, a body part with a thing, a symbol of manhood with a punctureproof balloon. Whether today's erection entrepreneurs truly grasp the psychological aspects of man's relationship with his penis or not, their treatment breakthroughs have permanently altered that mental bond -- chemically dissolving its most puzzling part. That, of course, is the control issue, a question that has shaped that relationship, for better and worse, for all of history. Now man can hold his manhood in his hand, confident in knowing who is in charge. When a man uses the products of the erection industry, his penis works for him.

This is more than a temporary jolt in the balance of power. It is a paradigm shift and a revolutionary restructuring of the masculine mystique. That mystique -- and the psychic vault of attitudes, aptitudes, and anxieties which give it so much confusing urgency -- compels man to impose his will on the world. Yet man has not always been able to impose his will on his penis, the flesh-and-blood symbol of that mystique. The penis used to have a mind of its own. Not anymore. The erection industry has reconfigured the organ, replacing the finicky original with a more reliable model. But the price tag for this new power tool is hidden. Eventually, we'll learn if we can afford it.

Copyright 2001 by David M. Friedman