"'Cause what the world needs now / is another folk singer / like I need a hole in my head."
—from "Teen Angst (What the World Needs Now)" by Cracker

Like a hole in my head, I need. And this is part of the problem these days. The incessant demands and desires for things I shouldn't need—these odd obsessions and unmanageable thoughts--and how they carve out a space in my head like the small rodent who nests in our attic at night. I can hear him skittering around in my skull when I wake, anxiety-ridden at 3 am, worried about an email I didn't send, the balance in my checking account, my inevitable loneliness, or whether my wife still exists. Sometimes I'm so far away I don't believe she is even real until I reach a hand out in the night to touch her, pushing through the veil of distance between us, letting my palm cup the round pajama-covered curves of her bottom. Some days this is as close as we will get. Some days it is all I need. Other days I never bridge the gap.

I would make a terrible Buddhist. I don't know how to turn off the voices. I am made of desire. I need you to understand this. And some nights, I don't know if the mouse in the ceiling is real or simply a manifestation of my generalized anxiety.

Technically we have numerous holes in our heads already; there's the obvious ones—eyes, mouth, nose, ears—seven if you count the nose as two holes. And the general consensus is that we don't need any additional excavations, just as we perhaps do not need any more folk singers.

My father has an extra one. His other hole is covered by a layer of skin now. But if you rub a finger over the spot on the right side of his head, you can feel the hard ridges of the entry. He doesn't remember the drill. He remembers the stars.

In the Hieronymus Bosch painting, "The Extraction of the Stone of Madness," we find a man seated in a chair at table in a garden or a yard. Depicting the medieval practice of trepanation, the painting offers a kind of parallel, an echo of an image, the resonance of the cut. It was believed that "madness" or psychotic behavior was located in a "stone" in the sufferer's head and, thus the only cure was to remove the stone. In Bosch's vision, the seated madman leans back, his mouth agape, his belly bulging beneath a white tunic. Another man standing nearby who looks like a priest holds a bottle or chalice of some kind, while a woman leans over a small table with her head propped up on her right hand as if she's watching a show. On her head she balances a large book. Behind the seated man, stands the surgeon. Dressed in a long smock and a pointed metal funnel hat that looks as if it was harvested from a stove-pipe, the surgeon holds a large scalpel. He cuts into the seated man's head, making an extra hole. And we see this—the ribbons of blood matching the stitches on his shirt, and a flower blooming from the wound.

The other hole, ideally, does not exist but it takes up space in the marriage. It takes up space in our heads. It is the emptiness the disconnect, the hamster wheel spinning, the other possibility. It is the rodent in the walls at night, the distance between the noise and the knowing. It is the gap between what is said      and    what    is     heard, what     is               believed.

Once when I was studying creative writing in graduate school, I suffered an ear infection, something I believed only happened to children. The pain was intense, so overwhelming that nothing could soothe it. Desperate for some relief, I sat on our sofa and slipped the tip of a cold Phillips-head screwdriver into my ear canal. I held it there, pressing gently against the inflammation, feeling the instant relief of cold steel. I wanted to plunge it deeper, to burst whatever infection boiled deep inside my ear. I wanted the release, the rush of blood and pus. But I also wanted to hear out of both ears, so I had to wait for a doctor to prescribe antibiotics. I had to leave the pain alone. I pulled the screwdriver out of my ear and held it in my hand. I stared at the blunt instrument, this tool of trades, and wondered how it might open me.

My father owns a phalanx of barbeque grills. Propane, charcoal, off-set wood smoker, and some kind of infra-red grill thing that probably cost more money than sense. He cares about cooking meat. He'll spend hours out there, tending to a brisket or pork roast, maybe a rack of ribs. He often wakes in the middle of the night to stoke the fire, baste, and tend his meat. And perhaps it was one of these middle-of-the-night or early morning journeys when he took his fall. Dad's foot tangled in a garden hose and he stumbled, hitting the right side of his head on a rock. He said he saw "stars" and felt a little woozy afterward. What he didn't know was that rock had broken blood vessels inside his skull. What he didn't know was that another hole was already inevitable. What he didn't know was how a fist can grow.

Some nights I imagine drilling holes in the ceiling to let out the mouse. Some nights I think this will work. Some nights I can trick my brain. I can think to stop the thinking. I play a little game. I picture all the players. The University of Kansas men's basketball starting five. Face, number, name. I go through them in order. Counting down. Some nights I drill deep into the bench. Others I don't make it past two or three before the mouse is quiet.

I know what you might think. Suicide is the other hole. But that's not my story. That's not this story. That kind of intrusion is too fast, too devastating. I'm interested in the effort of trepanation, the time it would take, the sound of commitment. I'm interested in the work. The subjugation, the offering of your head to another's touch, to their drill. I'm interested in the management of absence. I'm interested in the carve and the cut and the flower.

My wife has a small bone tumor, a kind of benign nub that pokes out from the right side of her head. You could only see it if she shaved her head. It's like a horn that isn't done, an antler interrupted. It is the opposite of a hole. It's a hernia of bone. I used to joke that her brain was too big for her skull and was trying to burst out. Sometimes her horn hurts and she'd worried for a while that it was something worse, something inside. A brain tumor bulging. The remnant of some wound. If you run a finger across her skull, you can feel the lump. At home she used to keep a CT scan of her skull taped on the wall above her desk, glowing white, a halo of orange around it, and the tiny horn protruding like a trophy. 

At its most basic level, the practice of trepanation is still used to relieve pressure underneath the surface of some membrane. If you've ever smashed your fingernail or toenail and had blood pool beneath it, perhaps a doctor drilled a small hole to relieve the pressure. That is trepanation. Or perhaps you were tending to a brisket on the smoker when you tripped, fell, and cracked your skull on a rock. Perhaps you didn't know it, but a blood clot began slowly forming beneath the surface of your skull, exerting pressure and pushing against that hard membrane.  And you didn't know that the pool of blood had grown to the size of human fist, nearly flattening one whole hemisphere of your brain. You only knew the incessant headaches, the never-ending pain. You only knew those days you forgot how to get to work. You only knew that words eluded you, dropped completely from your consciousness. You only knew that something was wrong inside. Two days later the doctors would drill an extra hole in your skull and drain the blood. Only then would you know the cut of trepanation. Only then would you call your son.

I tell my therapist that I swear I can hear my thoughts spinning in my head. Like a wheel. Like an engine churning. It is audible and terrible. I tell her it feels like I'm full of bees. Some nights the thoughts rattle down my legs in tiny tremors. Anxiety quakes through my body and I am struck by the seismicity of thought and feeling. On these nights, sometimes the only thing that soothes is my wife's touch. I reach a hand out for solace, pushing again through the distance. I curve into her, trying to absorb her warmth. Occasionally she recoils, stung by my chill. Other times she folds into me, giving into my weight, understanding that I am too much sometimes with all the loss I carry, all my needs and desires. I wish I could scrape them from my hull like barnacles off a boat. I wish I could float better through my days.

Twenty-eight, I tell myself. Twenty-eight holes is my best guess for a total number of holes in a human skull. Twenty-one of them are called femora, three each in seven bones at the base of the skull, carving pathways for nerves, arteries, veins, and blood vessels. It's always at night, 2 to 3 a.m., when the spin begins to weigh me down and I feel myself wobble and tip. Into irrational thoughts. Into fear and counting holes. And the feeling that something is wrong, even if I can't put my finger on it. These nights I wish I had another hole self-augured into my skull. I wish I had a release valve. I'd install a little tap handle to relieve the pressure. It would whistle and hiss when I twist a tiny knob. It would let out all the loss. It would leave me weightless.

The meningeal layer is a protective layer of fluid that surrounds the brain and the spinal column; and when it gets infected, it inflames and pushes against the skull. In the summer of 2002, I was stung by a mosquito carrying a virus. At first, my illness presented as a fever, fatigue, vomiting, and searing headaches. I could barely move and it felt as if someone or something was trying to shove my brain out through my eye-sockets. I was diagnosed with migraines, then the flu, then I was sent to the Emergency Room, where a doctor threaded a long needle into my spine, twisted the tap handle and drew out meningeal fluid to test for infection. They did not drill a stent to release the pressure. They did not install a valve. They pumped me full of anti-biotics and fluids and, within a day or two, the infection subsided and the headaches did, too. But it took months for my brain to feel the same again.

Trepanation, or trepanning, has a long history. The word itself is derived from the Greek word trypanon, meaning "borer or augerer." Practiced by native cultures for centuries and still practiced today (but for very different reasons), trepanation was originally thought to relieve pressures in the head due to headaches, injuries, illness or disease. It involved boring, drilling, or scraping a hole in the skull of the suffering patient. It was also used to treat mental illness, abnormality, and to release evil spirits.

The accomplished violinist reclines in a hospital bed, draped in blue. I see her image on the news. And I feel this overwhelming need to be there with her in some way. This is one of those odd obsessions. A plastic screen descends from above, and falls across the violinist's forehead, fastened tight with medical tape. Behind the screen a light reflects and fragments. Shapes are fixed but blurry, indeterminate, still dressed in the same blue. These are the doctors, the surgeons. With her left hand, the violinist holds her instrument. I wonder what she must be thinking. And it feels as if I am watching this tableau through a window into my future. With her right, the hand in question, she clutches the bow, ready for music. Behind the plastic screen, the surgeon clutches a different instrument. She needs him to be careful. He needs her to play. They've put an extra hole in her skull, exposing her brain and the tumor residing here. I wonder how she knew something was wrong. Was it a headache that never ends? Was it a mouse in the ceiling? I can see my reflection in the glass. The other side is cold and white and something beeps rhythmically in the background. The doctor must remove the cancerous mass, but he must do so without damaging the part of her brain that controls her right arm and hand. Without this arm she can only hold the un-bowed violin under her chin, silent and sorry. The challenge is to save her without killing her music. To remove the fist without losing the self. So, they ask her to play, to resonate. They need her to bow her cherished instrument, the notes echoing trough the surgical suite, filling the room with warm and generous sound, the kind of sound that feels like a map that reminds you where you are. So, she plays as the surgeon carves carefully into her brain, cleaving the cancerous mass from the rest, careful not to sever the nerve of genius. Think of the pressure. Think of the weight of the cut. Think of my love for her and the violin tucked under her chin, clutched there like a heart monitor. Think of what might bloom and flower. My breath fogs the glass distance that separates us, a barrier mostly of my own making. I consider the hole of existence, the absence, the space between any two people, and the demands of empathy. My fingers are still pressed against the glass. Waiting. For a window to what I need.

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The essay really started or found its form with the violinist. I saw a news story about her surgery and (sorry) couldn't get her out of my head. I've always been fascinated by the practice of trepanation and I think I knew the essay would eventually end with her. I just didn't know how I'd get there.