FIFTY YEARS AGO a surgical team led by Dr Joseph Murray in Boston, Massachusetts, performed the first successful transplant on a human being. An identical twin dying of chronic glomerulonephritis was given a kidney from his brother. The recipient lived for nine years before his condition caught up with him and he died. Since then, the number of transplant operations runs into thousands a year in the US, and recipients live longer and longer.

A recent issue of the The New England Journal of Medicine carries an excellent summary of the history of transplantation. It also carries a review of a book describing the rise of Viagra, and how this little blue pill has changed sex in America and the rest of the sophisticated world.

Transplant surgery epitomises the advances in medicine that prolong life and its quality for many with life-threatening conditions. Similarly, the advent of Viagra has significantly changed many people’s sex lives. It is a good example of the change in medicine in that it now deals not only with potentially life-and-death conditions, but also aims to enhance everyday life.

In the UK, medicine that treated discomfort, or disabilities that were a nuisance rather than a danger, used to be available only to the privileged few. The former insurance-club doctor, or doctors working in the city institute surgery paid for by the ratepayer, would have looked askance at a man in his sixties or seventies and with kidney disease, Parkinson’s disease or a clutch of other conditions who came in to complain that his penile performance was below par. The doctors would have been even more surprised had the patient asked for some costly treatment to improve his sexual ability so that, as the journal describes it, his ageing masculine identity, self and social worth could be boosted by prescription of some pills to be provided by the State.

The treatment of impotence is only one example of the change in demand that has occurred since the start of the NHS. The type of medicine that catered for the preservation of comfort and the alleviation of minor symptoms, was once available only to the middle class. Now everyone, rightly, expects it. Even if I, as a patient, lament that as yet no pharmaceutical company has introduced a treatment for impotence that can transcend the problems that are often caused by radical prostatectomy, as a doctor I welcome these changes.

Viagra, and the other drugs that act in a similar way, have changed the sex lives of the older generation. Two important messages still, however, need to be understood. Impotence is an important medical symptom that needs investigation. If its cause is obvious — a radical prostatectomy, for example — there is no anxiety about a possible previously undetected condition. If the reason is obviously physical but its mechanism uncertain, and even though one of the Viagra group of drugs overcomes its effects, its cause needs to be investigated. Increasing impotence is too often the first sign of generalised cardiovascular disease for it to be dealt with by symptomatic treatment only. The state of the penile arteries often reflects the condition of the coronary arteries and the carotids, the arteries in the neck leading to the brain. Both need to be assessed. Likewise, blood tests to exclude diabetes are called for.

There are two other drugs, Levitra and Cialis, that act in a similar way to Viagra. Which of these three drugs is best suited to a patient can sometimes be determined only by experiment. Cialis works within 30 minutes, and if sexual stimulation is repeated at any time during the next 36 hours, it still has a beneficial action. However, the price of prolonged effectiveness is that its side-effects, if any, are also more persistent.

Levitra seems to help a wider range of patients with impotence but has a speed of action between that of Viagra and Cialis. Viagra Mk 2 is expected before long, as are similar preparations for women.