In 1976, due to the actions of a California group of psychiatric survivors, Network Against Psychiatric Assault (NAPA), the psychiatric survivor movement scored a major victory (Hudson, 1978, p. 146). NAPA had attained for the state of California the first semblance of informed consent for EST in the United States (perhaps the first semblance of informed consent anywhere for persons labeled "mentally ill"). At least 30 other states enacted similar rule changes within the next few years. Psychiatrists in state institutions had to begin asking patients if they wanted EST. In these institutions, where EST had been predominantly administered up to this time, shock was, for a period at least, largely abandoned. At about this time too, shock devices came under the scrutiny of the FDA. It was time for the shock industry to take a different approach.

Also in 1976, psychiatrist Paul Blachley helped launch an attempt to make shock respectable again in America. A major part of a campaign to alter and improve the now very negative image of shock came in the form of "new and improved" EST devices, specifically the resurgence of Liberson's BP machine. Blachley's new company, Monitored Electro Convulsive Therapy Apparatus (MECTA), was soon followed by Somatics, Elcot and Medcraft in producing the "safer wave form," or BP ECT, devices. (13) With these newer devices, hospitals began, as standard procedure, to anaesthetize patients, the great majority of whom were now private hospital patients with insurance.

A recent New York Times article lauded the "modern" brief pulse models as "improved," and having modifications "like reduced doses of electricity" (Foderaro, 1993, p. A16). Recently, the television show 48 Hours featured psychiatrist Charles Kellner of the Medical University of South Carolina, who regularly administers electric shock. Kellner stated: "Well, it's such a different treatment now that there's almost no comparison...It really is a different treatment now...Having the seizure is the therapeutic part of ECT; probably about one fifth of the electricity that was used in the old days..." Such claims are false or misleading: the new BP devices are neither lower stimulus nor lower current devices than the older, or even the newer, SW models.

All other electrical components being equal, simple unmitigated BP (systematic interruptions of SW current) does in fact lead to reduced electrical dosages. However, aware that convulsions alone, induced by simple BP, are ineffective, manufacturers of modern BP devices amplify all other electrical components in order to compensate for the interruptions. Therefore, modern "souped up" BP apparatuses re-equal the cumulative electrical charges of the Cerletti-Bini style SW in every respect. For instance, 100 percent power of standard SW will emit the same 500 millicoulombs of electrical charge as 100 percent power of a modern BP machine such as Somatic's Thymatron DG. While one would expect reduced charges with BP, in fact, the old standard SW, i.e. Medcraft's 1950 model, emits slightly less charge than the modern day BP Thymatron DG. This would not be possible without electrical compensation of BP devices.

This compensation is accomplished in the following ways:

(a) The frequency is increased. Frequency is the number of pulses of electricity per second flowing past a given point. Although sine waves are "wider" than brief pulses, they are emitted at a constant rate of 120 per second. In comparison, modern BP devices can emit up to 180 pulses per second of electricity (e.g., MECTA's SR-2 and JR-2), or up to 200 pulses (Elcot's MF-1000).

(b) The current is increased. Current can be defined as electron flow per second and is measured in amperes or milliamperes (mA). The old SW devices deliver between 500 and 600 mA of current. The new BP Thymatron DG by Somatics delivers 900 mA constant current, the MECTA SR/JR devices, 800 mA, and the Medcraft B-25 BP up to 1000 mA or one full ampere.

(c) Duration is increased. Duration is the amount of time the current flows through the brain. Maximum duration of modern BP machines is four to six times the maximum duration of the older SW models.

(d) Wave lengths can be increased in most modern BP devices. The Elcot MF-1000, for instance, has adjustable brief pulses from a typical on msec up to an atypical two msec. A standard SW is 8.33 msec.

(e) Alternating current is used. In spite of the fact that both Liberson and Wilcox utilized DC successfully to induce adequate grand mal convulsions, modern BP devices utilize AC.

Thus modern BP devices are made to equal the charge (14) of SW devices in every consideration with respect to percent of energy utilized. In addition, they surpass the older SW machines in energy output (joules), or actual power emitted. (15) The following electrical features account for this increase:

(a) Much higher voltages are utilized. For example, the Thymatron DG utilizes up to 500 volts; the MECTA SR/JR, up to 444 volts; the new Medcraft up to 325 volts; and the Elcot MF-1000 up to 500 volts. Compare this to between 120 volts maximum for the oldest sine wave models and 170 volts maximum for modern SW devices.

(b) Constant current and continually increasing voltages are properties of all modern BP devices. Constant current means that the current never fluctuates or descends. This unique feature of BP devices is accomplished by higher and increasing voltages, a characteristic not found in SW devices. The constant lower voltage in the latter results in gradually decreasing currents. Just as the resistance of a wooden wall can eventually slow down and overpower an electric drill, so the human skull gradually slows down current. Modern BP devices maintain a constant current of about one ampere throughout the full four to six seconds it is emitted, making these devices the most powerful in ECT/EST history.

The tremendous energy output of modern BP devices (see footnote 15), the best measure of the machine's potential destructiveness, is a well-kept manufacturer's secret. The modern day BP devices are more than four times as powerful as the older SW devices, and about two and a half times as powerful as modern day SW devices. In fact, today's "new and improved" BP device is over eight times more powerful than the original Cerletti-Bini device renowned for permanent memory loss and upon which Wilcox and Liberson attempted to improve. Modern day BP devices have not been shown to be cognitively advantageous to SW devices in any modern study, and the few studies which have claimed cognitive advantages with modern day BP could not be replicated by other researchers (see Squire and Zouzounis, 1986; Weiner, Rogers, and Davidson, 1986a, 1986b).

Contrary to the claims put forth by the four manufacturers of EST devices, the evidence reviewed in this paper clearly shows that the majority of EST recipients report damage as a result of EST. EST recipients - whether or not they report memory loss - do, in fact, sustain actual permanent memory loss, averaging at least eight months, as a result of the procedure.

Modern day BP devices are not "lower current" machines, as most proponents claim. Through electrical compensation, they equal SW devices in every respect, and emit far greater energy. The results of studies claiming cognitive advantages using modern day BP over SW have not been replicated. any advantage of the original BP device has been attenuated in modern day devices.

Hundreds of studies conducted between 1940 and 1965 (Corsellis and Meyer, 1954; Hartelius, 1952; and Weil, 1942; McKegney and Panzetta, 1963; Quandt and Sommer, 1966) demonstrating brain damage have been criticized as old. However, since that time, the machines have only become more powerful. Thus few studies are old or irrelevant.

Most experts agree that current, and not convulsion (APA, 1992; Breggin, 1979, pp. 114, 122; Dunn et al., 1974; Sutherland et al., 1974) is responsible for long-term memory loss and severe cognitive dysfunction. Von Meduna's "therapeutic convulsion" is a myth, convincingly disconfirmed by early minimal stimulus convulsion experiments. Memory dysfunction and the "therapeutic" effect - which appear to be products of electricity - may well be inextricably related.

All four manufacturers continue to claim their devices are convulsive therapy devices. Nevertheless, because some of the Wilcoxian principles of the past are being rediscovered today, and because the efficacy of threshold convulsions is questionable (APA Task Force, 1990, pp. 28, 86, 94), a few BP manufacturers and researchers who collaborate with the manufacturers have gained enough confidence to call for even more powerful electrical devices - under the unsubstantiated claim that BP suprathreshold dosages of electricity are safer than SW suprathreshold dosages (Glenn and Weiner, 1983, pp. 33-34; MECTA, 1993, pp. 13, 14; Sackeim, 1991). For instance, Gordon (1980) rediscovered the adequateness of grand mal convulsions administered by low electrical dosages. Gordon (1982) later reiterated that high doses of electricity cause irreversible brain damage. Unaware of the lost history, Gordon suggested using minimal stimulus machines to induce convulsions. Deakin (1983) responded that minimal stimulus machines would be misguided, alluding to Robin and De Tissera's (1982) important double-blind study which demonstrated that current is the factor in ECT efficacy - not convulsions. (16) Sackeim, Decina, Prohovnik, Portnoy, Kanzler, and Malitz (1986) and Sackeim (1987) published studies corroborating the relevancy of electrical dosage to efficacy, and Sackeim restated this theme in a lecture delivered in New York in 1992 (Sackeim, 1992). Today's manufactures are quietly leaning away from von Meduna's convulsion theory, away from the concept of adequate convulsions at minimal dosage and toward an unobtrusive attempt to legitimize adequate or suprathreshold electrical dosages. (17) These tendencies, coupled with the power of modern BP devices, should lead to re-appraisal of the devices world-wide.

Manufacturers may have parted from the convulsion theory exemplified by just above seizure threshold devices of the past, to what might be just above damage threshold devices of the present, and if not forced to stop and prove the safety of their devices (allowing for even more powerful machines), might be embarking upon just above agnosognosic threshold apparatuses of the future.

In summary, modern electric shock machine companies are attempting to redefine safety from the original convulsion concept of "just above seizure threshold" to "safer wave form." The Food and Drug Administration must rescrutinize today's SW and BP devices, withdrawing their "grandfathered in" status under convulsive therapy devices. Because they utilize an entirely different principle, and because they are suprathreshold devices rather than convulsion-dependent devices, all modern day BP and SW EST device manufacturers must be required to prove machine safety to the Food and Drug Administration, prior to further utilization of new machines. All modern day SW and BP EST devices are more powerful than early instruments. Modern day BP suprathreshold devices have not proved safer than SW suprathreshold devices. Side effects have been convincingly identified as products of electricity. These facts warrant the elimination of all EST machines from the marketplace.