Professor of Clinical Neurology at Keele University Medical School and Consultant Neurologist in Regional Neuroscience Centre at Royal Stoke University Hospital. Master of Arts with Distinction (Celtic Studies) in School of Welsh and Celtic Studies at Bangor University, UK. Phone: 07862668966 Address: Wychbold, Queens Avenue, Colwyn Bay, LL29 7BE
MENTAL STATES of DAFYDD ap GWILYM.
Ceredigion 2023 (XIX/3), pp 1 - 18.
Medical practice in th... more MENTAL STATES of DAFYDD ap GWILYM. Ceredigion 2023 (XIX/3), pp 1 - 18. Medical practice in the medieval period was very different to modern times and there are instances in medieval Welsh poetry where this is implied. Indeed, mental health in medieval times was heavily linked to spirituality and religion and important instances of this have been discussed. For this paper, I have explored what can be concluded about the mental states or neurological conditions of Dafydd ap Gwilym. I will consider potential mental and neurological conditions from a detailed review of his poetry and compare this with what can be concluded from the love poetry of the troubadours in southern France. My interpretation of the evidence is based on my knowledge base and experience as a consultant clinical neurologist for more than twenty-five years and professor of clinical neurology for more than fifteen years.
MIND AND BODY IN MEDIEVAL WALES – THE EVIDENCE OF THE MEDDYGON MYDDFAI.
This article follows on... more MIND AND BODY IN MEDIEVAL WALES – THE EVIDENCE OF THE MEDDYGON MYDDFAI. This article follows on from my discussion of trepanation in medieval Wales in vol. 58 (2022) of this journal. Excerpts dealing with what we, today, term mental and nervous diseases from the manuscript of the ‘Meddygon Myddfai’ in the Red Book of Hergest, written in Middle Welsh, have been translated into modern Welsh and English and compared with other translations. Medical treatments practised in medieval Wales for different mental and nervous conditions are discussed. Carmarthenshire Antiquary 59 (2023), pp. 132-138.
Transactions of the Shropshire Archaeological and Historical Society 98 (2023), 9–16., 2023
Transactions of the Shropshire Archaeological and Historical Society 98 (2023), 9–16.
Mental il... more Transactions of the Shropshire Archaeological and Historical Society 98 (2023), 9–16. Mental illness, neurological conditions, and treatments from review of the medieval literature of Wales are presented and discussed. The Mostyn Medical Manuscript or 'Mostyn 88' attributed to Gutun Owain of Dudleston in Oswestry township, written in Middle Welsh and acquired by the National Library of Wales in Aberystwyth, is also reviewed and discussed. Currently this has not been translated into English in published form, and thus edited extracts of important sections relating to mental and nervous diseases have been translated from Middle Welsh to modern standardised Welsh orthography and translated into English. Figures from 'Mostyn 88' are introduced and discussed including a pictorial representation of sites for bloodletting used for different conditions, and an illustrated essay, the 'Zodiac man', with timing of bloodletting relating to the signs of the zodiac. Available treatments practised in medieval Wales for different mental and nervous conditions are summarised.
The Carmarthenshire Antiquary Vol 58 2022, pp5-14. , 2022
The Carmarthenshire Antiquary Vol 58 2022, pp5-14.
Trepanation in Medieval Wales
Clive Hawkin... more The Carmarthenshire Antiquary Vol 58 2022, pp5-14. Trepanation in Medieval Wales Clive Hawkins In the Red Book of Hergest the Meddygon Myddfai, Physicians of Myddfai, listed treatments and herbal remedies practised in medieval Wales. This article focuses on trepanation which involves making a hole in the skull and is described in some detail in the Red Book. The evidence for trepanation in medieval Britain is reviewed in the context of details from the practice of trepanation in Iron Age "Celtic’ Europe, Ancient Greece and the contemporary ‘medieval' society of the Incas. The frequency and sites of trepanation on the skull are discussed, and the proportion of subjects surviving with healing of the skull and the unusual occurrence of multiple trepanations in the same skull. The methods to carry out trepanation are reviewed and the medical rationale for practising trepanation is discussed. Conclusions are drawn about the practice of trepanation in medieval Wales.
Journal of Neurology, Neurosurgery, and Psychiatry, Oct 14, 2015
There is currently no treatment for secondary progressive multiple sclerosis (SPMS) which determi... more There is currently no treatment for secondary progressive multiple sclerosis (SPMS) which determines the majority of disability in multiple sclerosis. The MS-SMART trial is a multi-arm, multi-centre, phase 2 randomised trial for patients with SPMS. A total of 440 patients with progressing SPMS will be recruited in England and Scotland and randomised to one of 4 blinded arms: amiloride 5mg bd, riluzole 50mg bd, fluoxetine 20mg bd or placebo. These agents have been chosen after an extensive systematic review which has suggested putative neuroprotective properties. Patients will be followed up for 96 weeks with outcome data collected after 0, 24, 48 and 96 weeks. The primary endpoint is MRI atrophy rate. A wide range of relevant secondary and mechanistic exploratory outcomes will be collected including: MR spectroscopy, MTR, grey matter volume cervical cord atrophy, CSF neurofilament levels and optical coherence tomography. This trial is now open for recruitment in 2015.This independent research is awarded by the Efficacy and Mechanism Evaluation Programme (EME) and funded by the Medical Research Council (MRC) and the Multiple Sclerosis Society (MS Society) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.
Journal of Neurology, Neurosurgery, and Psychiatry, Oct 22, 2010
ABSTRACT Introduction MS is a chronic inflammatory disorder of the central nervous system. Whole ... more ABSTRACT Introduction MS is a chronic inflammatory disorder of the central nervous system. Whole genome analysis has identified discrete chromosomal regions outside the most powerfully associated MHC region that might harbour susceptibility genes: IL2RA, IL7R, TYK2, CD226 and CLEC16.(1-4) Genetic heterogeneity is likely to contribute to variability in MS outcome. Methods We examined nine single nucleotide polymorphisms (SNPs) in eight genes in 742 MS with MS severity score being used as the disease outcome using linear regression statistical analysis (STATA). Results Mutant allele (GG) of SNP rs2104286, in gene IL2RA on chromosome 10p15, was associated with better disease outcome: p=0.004, coefficient=-1.23, 95% CI -2.1 to -0.4. Wild type allele (CC) of SNP rs763361, in gene CD226 on chromosome 18q22.3, was associated with better disease outcome: p=0.002, coefficient=-0.86, 95% CI -1.4 to -0.33. We detected no significant impact on disease outcome for the remaining 7 SNPs. Discussion We have demonstrated that polymorphism in IL2RA and CD226 genes appears to have significant influence on the disease outcome in our MS population. As novel therapies become more widely available for treatment of MS, risk assessment and response to therapy could soon be influenced by detailed genotype analysis in individual patients.
Background: Multiple sclerosis outcome may be influenced by ultraviolet radiation and vitamin D s... more Background: Multiple sclerosis outcome may be influenced by ultraviolet radiation and vitamin D synthesis, suggesting skin type and genes determining this phenotype are candidates for disability. However, though associations between melanocortin 1 receptor (MC1R) single nucleotide polymorphisms and disability are reported, some data are incompatible with their expected influence on skin type. Objective: Determine which MC1R single nucleotide polymorphisms affect disability and establish if ultraviolet radiation modifies such associations. Methods: We studied using linear regression in 525 cases, associations of the Multiple Sclerosis Severity Score (MSSS) with skin type, gender, ultraviolet radiation exposure and six MC1R single nucleotide polymorphisms (rs1805005, rs1805006, rs2228479, rs1805007, rs1805008, rs1805009). Results: CG294 with GG294 genotypes (rs1805009) (coefficient = —1.44, 95% CI —2.30, —0.59, mean MSSS ± SD = 4.33 ± 2.87) and AC84 (rs1805006) (coefficient = 1.62, 95% CI 0.17, 3.06, mean MSSS = 7.62 ± 2.43) were associated with MSSS. Associations with Asp294His were found in those with skin types 1/2 and 3/4, and cases stratified by ultraviolet radiation exposure. However, they were seen only in cases with a history of childhood sunburn and not in those without sunburn. We found no significant associations between exposure parameters and MSSS. Conclusions: Multiple Sclerosis outcome is influenced by interactions between host response to ultraviolet radiation and MC1R single nucleotide polymorphisms. The influence of the single nucleotide polymorphisms appears distinct from their association with skin type.
We studied the relationship between abnormalities shown by MRI and functional disturbances in the... more We studied the relationship between abnormalities shown by MRI and functional disturbances in the visual pathway as assessed by the visual evoked potential (VEP) in 25 patients with established multiple sclerosis (MS); only 4 of whom had a history of acute optic neuritis. Optic nerve MRI was abnormal in 19 (76%) and is thus useful in detecting subclinical disease. Optic nerve total lesion length and area on the STIR sequence was found to correlate significantly with prolongation of the VEP latency. This may reflect a predominantly demyelinating rather than inflammatory origin for the signal change in the optic nerve.
Fluid-attenuated inversion recovery (FLAIR) imaging with prolonged inversion times allows generat... more Fluid-attenuated inversion recovery (FLAIR) imaging with prolonged inversion times allows generation of highly T2-weighted images of the brain with suppression of cerebrospinal fluid signal. Such sequences result in high lesion contrast and allow visualisation of abnormalities not seen with conventional T2-weighted spin-echo sequences. We used FLAIR sequences, proton density (PD) and standard T2-weighted images to examine lesion number and distribution in ten patients with clinically definite relapsing multiple sclerosis (MS). We also studied the extent and distribution of blood-brain-barrier breakdown by gadolinium-enhanced T1-weighted images. FLAIR sequences proved feasible both in terms of acquisition time and image quality using a 0.5 T imager. FLAIR imaging allowed identification of 45% more high-signal lesions than T2-weighted or PD images in the 10 patients. In particular, 60% more lesions within the cortex and at the grey-white interface were identified. Cortical lesions, none of which enhanced following gadolinium-DTPA injection, were present in seven of the ten patients studied. Of all lesions identified, 8% were cortical. FLAIR sequences are more sensitive to cortical and subcortical lesions in patients with active demyelination.
MENTAL STATES of DAFYDD ap GWILYM.
Ceredigion 2023 (XIX/3), pp 1 - 18.
Medical practice in th... more MENTAL STATES of DAFYDD ap GWILYM. Ceredigion 2023 (XIX/3), pp 1 - 18. Medical practice in the medieval period was very different to modern times and there are instances in medieval Welsh poetry where this is implied. Indeed, mental health in medieval times was heavily linked to spirituality and religion and important instances of this have been discussed. For this paper, I have explored what can be concluded about the mental states or neurological conditions of Dafydd ap Gwilym. I will consider potential mental and neurological conditions from a detailed review of his poetry and compare this with what can be concluded from the love poetry of the troubadours in southern France. My interpretation of the evidence is based on my knowledge base and experience as a consultant clinical neurologist for more than twenty-five years and professor of clinical neurology for more than fifteen years.
MIND AND BODY IN MEDIEVAL WALES – THE EVIDENCE OF THE MEDDYGON MYDDFAI.
This article follows on... more MIND AND BODY IN MEDIEVAL WALES – THE EVIDENCE OF THE MEDDYGON MYDDFAI. This article follows on from my discussion of trepanation in medieval Wales in vol. 58 (2022) of this journal. Excerpts dealing with what we, today, term mental and nervous diseases from the manuscript of the ‘Meddygon Myddfai’ in the Red Book of Hergest, written in Middle Welsh, have been translated into modern Welsh and English and compared with other translations. Medical treatments practised in medieval Wales for different mental and nervous conditions are discussed. Carmarthenshire Antiquary 59 (2023), pp. 132-138.
Transactions of the Shropshire Archaeological and Historical Society 98 (2023), 9–16., 2023
Transactions of the Shropshire Archaeological and Historical Society 98 (2023), 9–16.
Mental il... more Transactions of the Shropshire Archaeological and Historical Society 98 (2023), 9–16. Mental illness, neurological conditions, and treatments from review of the medieval literature of Wales are presented and discussed. The Mostyn Medical Manuscript or 'Mostyn 88' attributed to Gutun Owain of Dudleston in Oswestry township, written in Middle Welsh and acquired by the National Library of Wales in Aberystwyth, is also reviewed and discussed. Currently this has not been translated into English in published form, and thus edited extracts of important sections relating to mental and nervous diseases have been translated from Middle Welsh to modern standardised Welsh orthography and translated into English. Figures from 'Mostyn 88' are introduced and discussed including a pictorial representation of sites for bloodletting used for different conditions, and an illustrated essay, the 'Zodiac man', with timing of bloodletting relating to the signs of the zodiac. Available treatments practised in medieval Wales for different mental and nervous conditions are summarised.
The Carmarthenshire Antiquary Vol 58 2022, pp5-14. , 2022
The Carmarthenshire Antiquary Vol 58 2022, pp5-14.
Trepanation in Medieval Wales
Clive Hawkin... more The Carmarthenshire Antiquary Vol 58 2022, pp5-14. Trepanation in Medieval Wales Clive Hawkins In the Red Book of Hergest the Meddygon Myddfai, Physicians of Myddfai, listed treatments and herbal remedies practised in medieval Wales. This article focuses on trepanation which involves making a hole in the skull and is described in some detail in the Red Book. The evidence for trepanation in medieval Britain is reviewed in the context of details from the practice of trepanation in Iron Age "Celtic’ Europe, Ancient Greece and the contemporary ‘medieval' society of the Incas. The frequency and sites of trepanation on the skull are discussed, and the proportion of subjects surviving with healing of the skull and the unusual occurrence of multiple trepanations in the same skull. The methods to carry out trepanation are reviewed and the medical rationale for practising trepanation is discussed. Conclusions are drawn about the practice of trepanation in medieval Wales.
Journal of Neurology, Neurosurgery, and Psychiatry, Oct 14, 2015
There is currently no treatment for secondary progressive multiple sclerosis (SPMS) which determi... more There is currently no treatment for secondary progressive multiple sclerosis (SPMS) which determines the majority of disability in multiple sclerosis. The MS-SMART trial is a multi-arm, multi-centre, phase 2 randomised trial for patients with SPMS. A total of 440 patients with progressing SPMS will be recruited in England and Scotland and randomised to one of 4 blinded arms: amiloride 5mg bd, riluzole 50mg bd, fluoxetine 20mg bd or placebo. These agents have been chosen after an extensive systematic review which has suggested putative neuroprotective properties. Patients will be followed up for 96 weeks with outcome data collected after 0, 24, 48 and 96 weeks. The primary endpoint is MRI atrophy rate. A wide range of relevant secondary and mechanistic exploratory outcomes will be collected including: MR spectroscopy, MTR, grey matter volume cervical cord atrophy, CSF neurofilament levels and optical coherence tomography. This trial is now open for recruitment in 2015.This independent research is awarded by the Efficacy and Mechanism Evaluation Programme (EME) and funded by the Medical Research Council (MRC) and the Multiple Sclerosis Society (MS Society) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.
Journal of Neurology, Neurosurgery, and Psychiatry, Oct 22, 2010
ABSTRACT Introduction MS is a chronic inflammatory disorder of the central nervous system. Whole ... more ABSTRACT Introduction MS is a chronic inflammatory disorder of the central nervous system. Whole genome analysis has identified discrete chromosomal regions outside the most powerfully associated MHC region that might harbour susceptibility genes: IL2RA, IL7R, TYK2, CD226 and CLEC16.(1-4) Genetic heterogeneity is likely to contribute to variability in MS outcome. Methods We examined nine single nucleotide polymorphisms (SNPs) in eight genes in 742 MS with MS severity score being used as the disease outcome using linear regression statistical analysis (STATA). Results Mutant allele (GG) of SNP rs2104286, in gene IL2RA on chromosome 10p15, was associated with better disease outcome: p=0.004, coefficient=-1.23, 95% CI -2.1 to -0.4. Wild type allele (CC) of SNP rs763361, in gene CD226 on chromosome 18q22.3, was associated with better disease outcome: p=0.002, coefficient=-0.86, 95% CI -1.4 to -0.33. We detected no significant impact on disease outcome for the remaining 7 SNPs. Discussion We have demonstrated that polymorphism in IL2RA and CD226 genes appears to have significant influence on the disease outcome in our MS population. As novel therapies become more widely available for treatment of MS, risk assessment and response to therapy could soon be influenced by detailed genotype analysis in individual patients.
Background: Multiple sclerosis outcome may be influenced by ultraviolet radiation and vitamin D s... more Background: Multiple sclerosis outcome may be influenced by ultraviolet radiation and vitamin D synthesis, suggesting skin type and genes determining this phenotype are candidates for disability. However, though associations between melanocortin 1 receptor (MC1R) single nucleotide polymorphisms and disability are reported, some data are incompatible with their expected influence on skin type. Objective: Determine which MC1R single nucleotide polymorphisms affect disability and establish if ultraviolet radiation modifies such associations. Methods: We studied using linear regression in 525 cases, associations of the Multiple Sclerosis Severity Score (MSSS) with skin type, gender, ultraviolet radiation exposure and six MC1R single nucleotide polymorphisms (rs1805005, rs1805006, rs2228479, rs1805007, rs1805008, rs1805009). Results: CG294 with GG294 genotypes (rs1805009) (coefficient = —1.44, 95% CI —2.30, —0.59, mean MSSS ± SD = 4.33 ± 2.87) and AC84 (rs1805006) (coefficient = 1.62, 95% CI 0.17, 3.06, mean MSSS = 7.62 ± 2.43) were associated with MSSS. Associations with Asp294His were found in those with skin types 1/2 and 3/4, and cases stratified by ultraviolet radiation exposure. However, they were seen only in cases with a history of childhood sunburn and not in those without sunburn. We found no significant associations between exposure parameters and MSSS. Conclusions: Multiple Sclerosis outcome is influenced by interactions between host response to ultraviolet radiation and MC1R single nucleotide polymorphisms. The influence of the single nucleotide polymorphisms appears distinct from their association with skin type.
We studied the relationship between abnormalities shown by MRI and functional disturbances in the... more We studied the relationship between abnormalities shown by MRI and functional disturbances in the visual pathway as assessed by the visual evoked potential (VEP) in 25 patients with established multiple sclerosis (MS); only 4 of whom had a history of acute optic neuritis. Optic nerve MRI was abnormal in 19 (76%) and is thus useful in detecting subclinical disease. Optic nerve total lesion length and area on the STIR sequence was found to correlate significantly with prolongation of the VEP latency. This may reflect a predominantly demyelinating rather than inflammatory origin for the signal change in the optic nerve.
Fluid-attenuated inversion recovery (FLAIR) imaging with prolonged inversion times allows generat... more Fluid-attenuated inversion recovery (FLAIR) imaging with prolonged inversion times allows generation of highly T2-weighted images of the brain with suppression of cerebrospinal fluid signal. Such sequences result in high lesion contrast and allow visualisation of abnormalities not seen with conventional T2-weighted spin-echo sequences. We used FLAIR sequences, proton density (PD) and standard T2-weighted images to examine lesion number and distribution in ten patients with clinically definite relapsing multiple sclerosis (MS). We also studied the extent and distribution of blood-brain-barrier breakdown by gadolinium-enhanced T1-weighted images. FLAIR sequences proved feasible both in terms of acquisition time and image quality using a 0.5 T imager. FLAIR imaging allowed identification of 45% more high-signal lesions than T2-weighted or PD images in the 10 patients. In particular, 60% more lesions within the cortex and at the grey-white interface were identified. Cortical lesions, none of which enhanced following gadolinium-DTPA injection, were present in seven of the ten patients studied. Of all lesions identified, 8% were cortical. FLAIR sequences are more sensitive to cortical and subcortical lesions in patients with active demyelination.
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Papers by Clive Hawkins
Ceredigion 2023 (XIX/3), pp 1 - 18.
Medical practice in the medieval period was very different to modern times and there are instances in medieval Welsh poetry where this is implied. Indeed, mental health in medieval times was heavily linked to spirituality and religion and important instances of this have been discussed. For this paper, I have explored what can be concluded about the mental states or neurological conditions of Dafydd ap Gwilym. I will consider potential mental and neurological conditions from a detailed review of his poetry and compare this with what can be concluded from the love poetry of the troubadours in southern France. My interpretation of the evidence is based on my knowledge base and experience as a consultant clinical neurologist for more than twenty-five years and professor of clinical neurology for more than fifteen years.
This article follows on from my discussion of trepanation in medieval Wales in vol. 58 (2022) of this journal. Excerpts dealing with what we, today, term mental and nervous diseases from the manuscript of the ‘Meddygon Myddfai’ in the Red Book of Hergest, written in Middle Welsh, have been translated into modern Welsh and English and compared with other translations. Medical treatments practised in medieval Wales for different mental and nervous conditions are discussed.
Carmarthenshire Antiquary 59 (2023), pp. 132-138.
Mental illness, neurological conditions, and treatments from review of the medieval literature of Wales are presented and discussed. The Mostyn Medical Manuscript or 'Mostyn 88' attributed to Gutun Owain of Dudleston in Oswestry township, written in Middle Welsh and acquired by the National Library of Wales in Aberystwyth, is also reviewed and discussed. Currently this has not been translated into English in published form, and thus edited extracts of important sections relating to mental and nervous diseases have been translated from Middle Welsh to modern standardised Welsh orthography and translated into English. Figures from 'Mostyn 88' are introduced and discussed including a pictorial representation of sites for bloodletting used for different conditions, and an illustrated essay, the 'Zodiac man', with timing of bloodletting relating to the signs of the zodiac. Available treatments practised in medieval Wales for different mental and nervous conditions are summarised.
Trepanation in Medieval Wales
Clive Hawkins
In the Red Book of Hergest the Meddygon Myddfai, Physicians of Myddfai, listed treatments and herbal remedies practised in medieval Wales. This article focuses on trepanation which involves making a hole in the skull and is described in some detail in the Red Book. The evidence for trepanation in medieval Britain is reviewed in the context of details from the practice of trepanation in Iron Age "Celtic’ Europe, Ancient Greece and the contemporary ‘medieval' society of the Incas. The frequency and sites of trepanation on the skull are discussed, and the proportion of subjects surviving with healing of the skull and the unusual occurrence of multiple trepanations in the same skull. The methods to carry out trepanation are reviewed and the medical rationale for practising trepanation is discussed. Conclusions are drawn about the practice of trepanation in medieval Wales.
Ceredigion 2023 (XIX/3), pp 1 - 18.
Medical practice in the medieval period was very different to modern times and there are instances in medieval Welsh poetry where this is implied. Indeed, mental health in medieval times was heavily linked to spirituality and religion and important instances of this have been discussed. For this paper, I have explored what can be concluded about the mental states or neurological conditions of Dafydd ap Gwilym. I will consider potential mental and neurological conditions from a detailed review of his poetry and compare this with what can be concluded from the love poetry of the troubadours in southern France. My interpretation of the evidence is based on my knowledge base and experience as a consultant clinical neurologist for more than twenty-five years and professor of clinical neurology for more than fifteen years.
This article follows on from my discussion of trepanation in medieval Wales in vol. 58 (2022) of this journal. Excerpts dealing with what we, today, term mental and nervous diseases from the manuscript of the ‘Meddygon Myddfai’ in the Red Book of Hergest, written in Middle Welsh, have been translated into modern Welsh and English and compared with other translations. Medical treatments practised in medieval Wales for different mental and nervous conditions are discussed.
Carmarthenshire Antiquary 59 (2023), pp. 132-138.
Mental illness, neurological conditions, and treatments from review of the medieval literature of Wales are presented and discussed. The Mostyn Medical Manuscript or 'Mostyn 88' attributed to Gutun Owain of Dudleston in Oswestry township, written in Middle Welsh and acquired by the National Library of Wales in Aberystwyth, is also reviewed and discussed. Currently this has not been translated into English in published form, and thus edited extracts of important sections relating to mental and nervous diseases have been translated from Middle Welsh to modern standardised Welsh orthography and translated into English. Figures from 'Mostyn 88' are introduced and discussed including a pictorial representation of sites for bloodletting used for different conditions, and an illustrated essay, the 'Zodiac man', with timing of bloodletting relating to the signs of the zodiac. Available treatments practised in medieval Wales for different mental and nervous conditions are summarised.
Trepanation in Medieval Wales
Clive Hawkins
In the Red Book of Hergest the Meddygon Myddfai, Physicians of Myddfai, listed treatments and herbal remedies practised in medieval Wales. This article focuses on trepanation which involves making a hole in the skull and is described in some detail in the Red Book. The evidence for trepanation in medieval Britain is reviewed in the context of details from the practice of trepanation in Iron Age "Celtic’ Europe, Ancient Greece and the contemporary ‘medieval' society of the Incas. The frequency and sites of trepanation on the skull are discussed, and the proportion of subjects surviving with healing of the skull and the unusual occurrence of multiple trepanations in the same skull. The methods to carry out trepanation are reviewed and the medical rationale for practising trepanation is discussed. Conclusions are drawn about the practice of trepanation in medieval Wales.