History of Neurosurgery for Mental Disorder (NMD)

Article Index

This information is from David Christmas' MD thesis, the full version of which is available on the site.


The convention regarding terminology has been one such that early (i.e. before stereotactic methods) references to psychiatric surgery adopt the contemporary title of the time, i.e. ‘psychosurgery’. Later procedures such as cingulotomy and capsulotomy are referred to as ‘NMD’ to reflect the change both in technique and thinking that accompanied these advances.

Traditionally, the history of Neurosurgery for Mental Disorder (NMD) begins with trepanation and at some point crosses paths with the story of Phineas Gage. Both are worthy of a mention in the preface. We should note that the history of NMD is not a smooth continuum of progress, but instead is simply one of recognisable steps.

Trepanation is not the starting point because it initiated a gradual evolution of surgical activity culminating in modern neurosurgery, but because we have clear archaeological evidence of such a human endeavour occurring early on in society and it give us an intriguing, and time-locatable point with which to begin the story. The two practices were guided by very different belief systems and medical contexts, and it would be foolish to link such early ‘surgical’ practices with those that emerged in the 19th and 20th Centuries.

The inclusion of Phineas Gage is more problematic. There is little to suggest that he influenced the development of psychosurgery to any degree yet his story refuses to go away. Reasons for this are discussed later in Section 3.3, but perhaps his oddly morbid tale simply appeals to us all.

A Prehistory of NMD

Trepanation (a.k.a. trephination), the deliberate creation of holes in a person’s skull, has been practised in various cultures for thousands of years. The trephined skull of a man in his fifties was discovered in France in 1996. Carbon dating revealed the skull to date from approximately 5100 B.C. Furthermore, the skull showed evidence of healing, suggesting that the man survived the procedure (Alt, Jeunesse, Buitrago-Tellez, et al, 1997). The practice was probably widespread throughout early human societies, and there is evidence of such procedures in parts of North Africa, Europe, Asia, and South America. Trephining knives have been discovered in excavated Inca settlements. Trepanation was frequently used to treat ‘spirit’ or ‘demonic’ possession, which was probably a primitive ‘diagnosis’ for many forms of mental illness, epilepsy, headaches, and other neurological conditions.

Trepanation (in various forms) has continued throughout the last two millennia. Such an intervention was being recommended for mood disorders in the 12th Century. Ruggio Frugardi, a physician from the Hippocratii School of Medicine at Salerno, Italy wrote that, “For mania and melancholy the skin at the top of the head should be incised in a cruciate fashion and the skull perforated to allow matter to escape” (Cited in O'Callaghan & Carroll, 1982, p. 4). Trepanation continues to be performed today by a small number of people, most of who believe that it can improve “brain pulsations” and hence overall well-being. The belief that brain pulsations have some impact upon health dates back to the work of Claudius Galen (c. AD 129 – c. AD 216) and despite there not being any scientific support for such beliefs, many modern devotees report positive health benefits (For example, see Henderson, 2000).


Alt, K. W., Jeunesse, C., Buitrago-Tellez, C. H., et al (1997) Evidence for stone age cranial surgery. Nature, 387, 360.
Henderson, B. (2000). Trepanation. BMEzine.com. Website. Last updated: Not Stated. Accessed: 16 April, 2006. Available at: http://www.bmezine.com/news/people/A10101/trepan/index.html
O'Callaghan, M. A. J. & Carroll, D. (1982) Psychosurgery: A Scientific Analysis. Lancaster: MTP Press.