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?