Editor’s note: Melissa Monroe offers us a poetic guide to trephination, the old cross-cultural practice of drilling a hole in the skull for purposes ranging from religious devotion to the relief of mental and physical ailments as they were conceived of in different locales and at different points in history. This wide-ranging poem, which plays out in economical tercets, reminded us a little of Marianne Moore’s relentlessly material, slyly humorous assemblages of encyclopedic bric-a-brac, full of quotations, preoccupied by detail, animated by mystery and hidden pathos.

The Evolution of the Androgynous Trephine

The earliest instruments
for entering the skull were chipped flints
and polished mussel shells.
 
The surgeon stabilized
the patient’s head by gripping it tightly
between his knees.
 
Inca practitioners
scraped four grooves “crossing each other at right
angles, and, when they were
 
sufficiently deep,
the resulting square of bone was prized
out of its bed.”
 
Afterwards, the aperture
was often “filled with a perfectly fitting
diaphragm of lead.”
 
In the West, circular
perforations were preferred, and heat-hardened
metal blades and drill bits
 
superseded makeshift
organic tools. The Greeks used a trypanon or augur
to bore “a wreath
 
of tiny holes.
These could be united easily
with a chisel or knife.”
 
The prototype
of the modern trephine, employed by Hippocrates,
was a conical crown
 
with a serrated lip
and “a cylindrical handle several inches long,
which was operated
 
by rapidly rolling it
between the palms.” A gimlet-like central
pin engaged
 
the tool in the bone
during the first turns, “until the toothed portion
had begun to bite.”
 
Although an advance
on the augur, this instrument still “offered both poor
control and uncertain
 
penetration”; an unplanned
breach of the dura mater frequently led
to fatal complications.
 
During the Middle Ages,
propulsion was improved with mechanisms “borrowed
from carpentry.” A brace
 
and then a drill stock replaced
the ergonomically inferior bi-palmar
rotated shaft.
 
A wider shoulder
was developed to prevent the saw
from slipping
 
into the meninges;
Fabricius accomplished the same goal by equipping
the crown with wings.
 
In his Chyrurgeon’s
Store House, Scultetus discusses what he calls
“male” and “female” trephines –
 
those with and without
the central pin. “Before we use the female, we must
make some print
 
upon the skull
with the male so that the female may stand
faster upon it.”
 
Frictional heat
could reach dangerous levels, and bone dust
soon clogged the teeth,
 
so the female crown
“was replaced now and then by another,
identical one,
 
whilst a helper
cleaned the used crown and cooled it in water
or attar of roses.”
 
In order to shield
the patient “from two possible sources of fright,
the sound of the drill
 
and the sight
of the instruments,” a piece of linen was draped
over the tools
 
and the patient’s ears
were “well stopped with Lint or Bumbast.”
Cold drafts
 
and strong emotions
were eschewed, and prudent surgeons did not operate
during a full moon.
 
The need to shift
from male to female crown was eliminated in
the eighteenth century,
 
when Samuel Sharp
of Guy’s Hospital designed an “androgynous” model,
fitted with a key.
 
A “‘male’ crown could
be transformed into a ‘female’ one by simply
taking out the point.”
 
Techniques evolved as well.
The cutting went more smoothly when the surgeon pressed
down on the handle
 
with his chin or forehead.
The “chin” and “mental” methods thus soon supplanted
the old “frontal” approach,
 
and the pigeon-blood
poultices prescribed by Galen were discarded in favor
of antiseptic dressings.
 
Since the mid-1900s,
the instruments have undergone little
further alteration;
 
Evans’ “attempt to marry
trepan and brace, employing a handle with
a universal joint,
 
never achieved
popularity.”  A brace designed by MacEwan
“was but an adaptation
 
of the early wimble,
and Roger’s ‘skull plough’ a reversion
to primitive times.”
 
Although “no longer viewed
as therapeutic in itself,” trepanation remains
an important procedure
 
still widely used
“in the management of head trauma,”
for exploratory
 
diagnosis, for
relief of pressure, “for debridement
of a penetrating wound,”
 
or to gain
access to the cerebrum “(for example
to provide
 
a port, through which
a stereotactic probe can be introduced
into the brain).”
 

The information in this poem is from the following sources:
 
Gross, C. (2003). Trepanation from the Palaeolithic to the Internet. In Arnott, Finger & Smith (Eds.), Trepanation: History, discovery, theory (pp. 307-322). Lisse, The Netherlands: Swets & Zeitlinger.
 
Hæger, K. (1988). The illustrated history of surgery. (Jon van Leuven, Trans.). New York: Bell.
 
Kirkup, J. (2003). The evolution of cranial saws and related instruments. In Arnott, Finger & Smith (Eds.), Trepanation: History, discovery, theory (pp. 289-304). Lisse, The Netherlands: Swets & Zeitlinger.
 
Rocca, J. (2003). Galen and the uses of trepanation. In Arnott, Finger & Smith (Eds.), Trepanation: History, discovery, theory (pp. 253-271). Lisse, The Netherlands: Swets & Zeitlinger.
 
Ruisinger, M. (2003). Lorenz Heister (1683-1758) and the “Bachmann Case”: Social setting and medical practice of trepanation in eighteenth-century Germany. In Arnott, Finger & Smith (Eds.), Trepanation: History, discovery, theory (pp. 273-288). Lisse, The Netherlands: Swets & Zeitlinger.
 
Thompson, C.J.S. (n.d.). The evolution and development of surgical instruments (the “trepan”). Retrieved May 14, 2006, from http://www.trepan.com