It has now become fashionable to declare brain damage from ECT a thing of the past because of "new refinements" in the procedure and in the machines (Coffey, 1993; Daniel, Weiner, and Crovitz, 1982; Foderaro, 1993; Kellner, 1994; Weiner, Rogers, and Davidson, 1986a). Breggin (1979, 1991) has debunked these "new and improved" claims, yet it appears that the strongest arguments in favor of ECT are the "new and improved" brief pulse machines. The implication that the sine wave device of old has been replaced by the brief pulse device of present lurks behind much of the continued use of ECT. The remainder of this paper shall examine the "new and improved" brief pulse device in light of the original aim and purpose of ECT.

Von Meduna introduced the concept of convulsive therapy in the 1930s (see von Meduna, 1938; Mowbray, 1959). He believed that a "therapeutic" or "anti-schizophrenic" effect could be obtained from the chemical induction of grand mal seizures. In 1938, Cerletti and Bini introduced electroshock treatment (EST), or convulsions induced without chemicals. The convulsion appeared to be eliciting what later came to be described as an "anti-depressant effect" (Alexander, 1953, p. 61). While "patients" were at first intimidated and terrified, after a series of ECT they appeared more cooperative, docile, apathetic, or in some cases even cheerier toward their physician. These "improvements" (as short-lived then as now), appeared to validate von Meduna's convulsion theory.

From the onset, the treatment also produced severe memory problems, openly acknowledged as brain damaging effects by any of a myriad of published papers during that era (Brody, 1944, Ebaugh, Barnacle, and Neuburger, 1942; Sakel, 1956; Salzman, 1947). At the time, both the "anti-depressant" effect and memory dysfunction were attributed to the convulsion. Gaining almost instant popularity among European psychiatrists, the machine was soon introduced into the United States, and by 1950 as many as 175,000 people annually may have been administered enforced ECT (Cohen, 1988; Robie, 1955).

A handful of professionals rejected the idea of brain damage as treatment (Delmas-Marsalet, 1942; Liberson, 1946; Wilcox, 1946; Will, Rehfeldt, and Newmann, 1948). One of them was Paul H. Wilcox, who by 1941 had concluded that the "therapeutic" effect of EST could be successfully separated from its brain damaging effects (Alexander, 1953, pp. 61-61; Friedman, Wilcox, and Reiter, 1942, pp. 56-63). Wilcox's own theory of electrostimulation challenged Meduna's theory. according to Wilcox (1946, 1972), perhaps it was simply electric stimulation of the brain which created the anti-depressant effect. Providing the correct dosage of non-convulsive electrical stimulation to the brain might elicit the therapeutic effects without the brain damaging convulsion.

This "non-convulsive therapy" failed to elicit the "therapeutic" effect (Impastato, 1952). However, in his quest to determine the ideal electrical dosage, Wilcox discovered that the strength of an electrically induced grand mal seizure did not depend upon any more electricity than that required to induce the seizure (Alexander, 1953, p. 64; Sulzbach, Tillotson, Guillemin, and Sutherland, 1942, p. 521). This meant that "adequate" convulsions could be induced with much lower dosages of electricity than had previously been used, and that the Cerletti-Bini devices were utilizing much more electricity than needed to induce such convulsions (Friedman, 1942, p. 218). Cerletti and Bini's device, then, was not an electroconvulsive device, but an electroshock device.

Wilcox reasoned that even if convulsions were necessary for the "anti-depressant" effect, by inducing convulsions with the least electricity dosage possible, side effects might be reduced or eliminated (Friedman et al., 1942; Impastato, Frosh, and Robertiello, 1951). Wilcox set out to build the first "true" ECT machine, which he completed in 1942 (see Friedman, 1942). By ECT Wilcox meant electrically induced "adequate" grand mal convulsions, utilizing electrical dosage minimally above seizure threshold. (7)

To build his machine, Wilcox collaborated with an electrical engineer named Reuben Reiter. Following Wilcox's instructions, Reiter first operationalized Wilcox's minimal dosage concept into a direct current (DC) device, as opposed to the Cerletti-Bini alternating current (AC) device. The power of the new Wilcox-Reiter machine was thus immediately reduced by half. Wilcox was able to induce equal or "adequate" grand mal convulsions (of at least 25 seconds' duration) with his new machine, showing the Cerletti-Bini EST apparatus culpable of electrical overkill (Friedman, 1942, p. 218). The Wilcox-Reiter machine approached the challenge of threshold convulsions differently than other devices: from below rather than above threshold. The machine depended upon the cumulative effect of the electricity in order to induce a convulsion, at the first indications of which the current was immediately abated. Wilcox, Friedman, and Reiter turned the switch on and off manually as fast as possible during an application, (8) which further reduced the current (Friedman, 1942, p. 219; Weiner, 1988, p. 57, Figure 3). Finally, in 1942, Wilcox and Friedman developed unilateral ECT (Alexander, 1953, p. 62; Friedman, 1942, p.218), a method to reduce seizure threshold, allowing even more reductions in electrical dosage. That usually consists of placing one electrode on the temple and the other on top of the head so that a single frontal lobe of the brain is shocked. Unilateral ECT is often touted today as a "new and improved" methodology (Weiner, 1988, p. 59).

These methods and refinements greatly reduced the dosage of electricity required to induce an "adequate" convulsion. Wilcox now attributed memory loss and brain damage to such excess electricity (Alexander, 1953, p. 62). The Cerletti-Bini EST device utilized up to 125 volts of electricity and up to 625 milliamperes for the Wilcox-Reiter ECT device (Alexander, 1953, p. 62; Impastato et al., 1951, p. 5).

Correspondingly, the Wilcox-Reiter device greatly reduced, but did not eliminate, side effects. This was shown in EEG studies comparing the Wilcox-Reiter with the Cerletti-Bini. For example, Wilcox (1946) and others (Liberson, 1949; Proctor and Goodwin, 1943) found a positive relationship between electrical dosage and abnormal or slow brain wave activity and memory dysfunction. Brain damage and memory dysfunction did indeed appear to be more a product of electricity than of convulsion.

Weiner (1988) criticizes the early comparative EEG studies as compromised by the possible use of unilateral ECT and other variations. Still, the relationship between memory impairment, brain damage and electrical dosage has been corroborated by various early and more recent studies (Alexander and Lowenbach, 1944; Cronholm and Ottosson, 1963; Dunn, Giuditta, Wilson, and Glassman, 1974; Echlin, 1942; Essman, 1968; Gordon, 1982; Liberson, 1945a; Malitz, Sackeim and Decina, 1979; McGaugh and Alpern, 1966; Reed, 1988; Squire and Zouzounis, 1986). Many of these studies compared the effects of electricity to those of other convulsive stimuli on brain tissue. The results implicated the electricity much more than the convulsion. Specific observations as a result of applying even sub-convulsive dosages of electricity to the brain include retrograde amnesia in animals (McGaugh and Alpern, 1966); constriction of arteries, arterioles, and capillaries passing through the meninges of the brain (Echlin, 1942); metabolic changes in the brain chemistry of animals (Dunn et al., 1974); permeability of the blood brain barrier (Aird, Strait, and Pace, 1956); and other evidence of brain damage or its effects. According to the APA Fact Sheet (1992) on ECT, spontaneous seizures, even lasting up to 90 minutes, do not cause brain damage. Breggin (1979, p. 118) also notes in his review on electrical damage to the brain, that "although convulsions of all kinds can cause biochemical disturbances in the brain, experienced researchers in the field believe that a case has been made for the electrical current as the main culprit."

First Brief Pulse

Also in the early 1940s, another psychiatrist, WT Liberson, who accepted von Meduna's theory, was inspired by the Wilcox discoveries to devise yet another method by which to reduce electrical dosage. Liberson (1945b, 1946, p. 755) is credited with producing the first "brief pulse" (BP) ECT device, using a systematically and continuously interrupted current. Because of the interruptions, each pulse of electricity becomes briefer than standard sine wave (SW) or relatively non-interrupted "wall" current. A single standard SW is 8.33 milliseconds (msec) long, compared to 1.0 msec for a single standard BP. The Wilcox-Reiter DC device cut the number of waves in half compared to the Cerletti-Bini AC device. Liberson adopted Wilcox's previous modifications and introduced electronically systematic continuous interruptions in the current as well (not merely the less efficient manual interruptions introduced by Wilcox), so that each individual pulse now became briefer.

For a time, Liberson's BP device was the one using the least electrical dosage and thus causing the least amount of memory damage (Alexander, 1953, p. 62; Liberson, 1945b, 1946, p. 755; Liberson and Wilcox, 1945). Both Wilcox's and Liberson's devices were ECT machines, in that their purpose and successful function was to induce constant strength grand mal convulsions with minimal dosages of electricity (Alexander, 1953, p. 64). However, could these new machines produce the same therapeutic or anti-depressant effect as the Cerletti-Bini devices? Did adequate convulsions without the higher electrical dosages still "work"? Would von Meduna's convulsion theory prove correct?

Brief Pulse Fails

Despite the advantages of the Liberson ECT device, physicians in clinical practice did not use it widely. Brief pulse devises may have been slightly more expensive to build. Also, the earliest BP device emitted such low electrical dosage that unconsciousness was sometimes induced by the convulsion rather than by the electricity. In these instances the ECT recipient remained conscious until the convulsion, resulting in even more apprehension than in unmodified (without anesthesia) high dosage SW EST (Liberson, 1948, p. 30). The problem was corrected by a slight increase in the pulse width or by the utilization of sodium pentothal or both (Liberson, 1948, pp. 30, 35). (9) Some psychiatrists believed fear to be a necessary dimension of the procedure and so increased apprehension may not have been a negative factor for physicians in using the device (Cook, 1940; Liberson, 1948, p. 37). However, most clinicians complained that the same anti-depressant effect attainable with high dosage EST devices could not be achieved with Liberson's low-current BP ECT device (Impastato et al., 1957, p. 381). Many psychiatrists were not convinced the treatment worked without the higher dosage of electricity and its accompanying side effects. In fact, since the treatment appeared less effective with reduced side effects, many practitioners held side effects to be desirable, an integral part of the treatment itself (Alexander, 1955).

Although Liberson claimed complete therapeutic success with his device, he soon began proposing more treatments per series - in fact, as many as thirty (Liberson, 1948, p. 38) Rationalizing, Liberson proposed "a relatively great number of BST (brief stimulus) treatments in order to consolidate the therapeutic results...As BP treatments are not followed by as much organic disturbance as with the classical ones, one should be particularly eager not to stop the treatments too early" (Liberson, 1948, p. 36). Liberson failed to explain why, if the anti depressant effect was a product of the adequate convulsion, a greater number of individual treatments would be required.

As early as 1948 then, it was known that, even with potent seizures, the anti depressant effect at low electrical dosages was simply not satisfactory. (10) Liberson (1946, p. 755) must have understood that electricity was the true therapeutic agent, but rather than publish findings showing von Meduna's convulsion theory weakened considerably, he focused instead on making his BP ECT device "work." After calling for more and more treatments, he recommended longer doses of BP ECT (Liberson, 1945b), eventually marketing a machine which allowed the current to flow between the temples for a full five seconds (compared to between 0.5 and one second previously). The Liberson device could no longer be called an ECT, but was now an EST device. Next, although Liberson had already increased the wave length duration from 0.3 to between 0.5 and one millisecond (11), his newer BP model offered adjustable wave lengths from between 1.5 to two milliseconds. The current was eventually stepped up to between 200 and 300 milliamps and finally, Liberson returned to AC - doubling the power.

All these modifications, of course, defeated the original purpose of the BP experiment: to induce adequate seizures at just above threshold electrical dosage. But even as Liberson continued increasing the anti depressant effect of his BP machines by augmenting the dosage of electricity in various ways, the machines still lacked the power of the original or newer Cerletti-Bini style EST devices. Physicians everywhere seemed to prefer the higher dosage machines for their greater effectiveness (Cronholm and Ottosson, 1963; Page and Russell, 1948). Eventually, Liberson stopped increasing the power of his own device any further.

No one, including Liberson, mentioned that the convulsion theory might have been shown false, that adequate convulsions by themselves did not appear to produce a therapeutic effect. Nor did anyone suggest that it was electroshock that psychiatrists preferred, not minimal dosage electroconvulsion at all. By the mid-1950s, the Liberson BP ECT series disappeared forever from the marketplace.

The Wilcox-Reiter Device

Just as Liberson originally adopted the Wilcox-Reiter modification of DC in lieu of AC, Wilcox and Reiter soon incorporated Liberson's electronic BP principle into their own device. Wilcox and Reiter held one additional advantage: a cumulative sub-convulsive technique culminating in just above threshold seizures. This allowed the Wilcox-Reiter devices to surpass even Liberson's BP in ability to induce grand mal convulsions with the least electricity possible. The Reuben Reiter Company (producer of the Wilcox-Reiter machine) continued to produce such ECT devices into the 1950s.

Even so, by 1953, it was apparent that the Wilcox-Reiter ECT "electro-stimulators" also began to decline in popularity and could not compete with the more powerful Cerletti-Bini style American EST machines (i.e., Radha, Lectra, and Medcraft). in December 1956, at the Second Divisional Meeting of the APA in Montreal, Canada, psychiatrist David Impastato (12) and his colleagues made this announcement:

These currents (unilateral currents of the previous Reiter machines) evoke convulsions after three to five or more seconds of stimulation. In view of this, we may call such convulsions threshold convulsions...The fracture rate is moderately reduced when these currents are used, but apnea, post-convulsive confusion and agitation and subsequent memory changes are greatly reduced. In spite of these advantages, the use of unidirectional currents has not found favor in all quarters because a number of observers feel that with these currents more treatments than with AC currents are needed to effectuate a remission or to quickly bring under control such abnormal behavior as unmanageable agitation and suicidal drives. The psychiatrist of this faith therefore continues to use the old AC current machines and makes the best of the undesirable side actions. (Impastato et al., 1957, p. 381)

This announcement was, in effect, the unprecedented concession that the Wilcox-Reiter experiment with ECT had failed; that adequate convulsion alone had not, according to clinicians everywhere, created the desired anti-depressant effect Wilcox, Friedman, Reiter, and Liberson had hoped for, 15 years earlier. ECT had failed and EST had emerged victorious. Almost all manufacturers of the popular SW devices recognized the "adequate dosage" precept. The more powerful their machines became, the more "effective" and commercially successful.

There was at this time no FDA, no physician adverse effect reporting system, no psychiatric survivor led civil rights movement, no informed consent requirements. In short, there was no one but the ECT investigator him/herself to announce that ECT had failed and that EST was producing the desired effects. It remained only for the investigator to report that there was no possibility of administering EST without the damaging effects, as both the damage and the "therapeutic" effect appeared to be the result of suprathreshold dosages of electricity. But neither Wilcox, Friedman, nor Reiter made any such announcement. Rather than challenge colleagues who were damaging the brains of thousands of persons yearly, Wilcox and Reiter, after voicing half-hidden resentment through Impastato's announcement and publication (Impastato et al., 1957) against those who failed to use the safer unidirectional minimal current ECT devices, then allowed Impastato and colleagues to introduce the newest Wilcox-Reiter machine, the Molac II, a Cerletti-Bini style SW AC device, capable of administering convulsions many times over seizure threshold. This was, in effect, the first deliberately designed Wilcox-Reiter EST apparatus.

The Molac II was announced as having a superior feature over "old" Cerletti-Bini style machines, a millisecond of high voltage current (around 190 volts) in order to render the person unconscious before delivering two to three seconds of AC current at around 100 initial volts. Ironically, Impastato and colleagues, just before the announcement of the new Molac II, had railed against the side effects of the "classic Cerletti-Bini EST machine," attributing them to "excessive current used" (Impastato et al., 1957, p. 381). There was no reason to believe the current intensity of the new device was any lower and whereas the original Cerletti-Bini machine could administer current up to five tenths of a second, the new Molac II had no timer at all. The recommended duration of each treatment was between two and three seconds, but this was left completely up to the doctor's discretion. The black button could be held down indefinitely!

After designing the least dangerous machine in history, Wilcox and Reiter had now designed the most dangerous EST machine in history, completely discarding their minimal dosage, adequate convulsion precept of ECT. Ironically, the Impastato et al. (1957) paper ended by claiming that Molac II recipients tested on the "Proteus Maze" did no worse than those who had been treated with previous minimal dosage machines, a contradiction of everything Wilcox, Friedman and Reiter stood for and had maintained for the previous 17 years. since December, 1956, there have been no ECT devices produced in America. The same experiment ended similarly in Europe (see footnote 7).

Next Section: The Case for Consumer Misinformation and Conclusions