I recently read Esther Cohen's The Modulated Scream: Pain In Late Medieval Culture, which is a study of the various ways pain was represented in treatises on torture, stories of martyrs, saints and mystics, and medical/surgical treatises and more. I read it for fairly obvious reasons which naturally resulted in me having Even More Thoughts On Henry V's face hole.
(n.b. 1) Bradmore's treatise nor the Middle English translation is not discussed by Cohen. 2) I do not have access to a full translation of Bradmore's treatise in modern English nor the Middle English translation, only his case histories.)
John Bradmore's treatise makes little to no mention of pain associated with wounds or pain management, at least as far as it relates to his case histories. The one exception is not Hal's wound but a case of an unnamed London carpenter "careless with his chisel" that left him haemorrhaging. In this case, Bradmore tries a variety of methods to arrest bleeding - first a pressure bandage, then cauterisation and then, seeing no other alternative and that his patient was in danger of dying, he used a "secret corrosive powder". He explains he resorted to this powder last as it is "so furious and harsh that it is most oppressive" to the patient, i.e. painful and possibly life-threatening. S. J. Lang suggests that the reference to pain served two functions - to warn other practitioners of the powder's nature and to explain why he did not use it to begin with.
Bradmore's otherwise lack of reference to his patients' pain is not unusual. Per Cohen, university-trained surgeons "often completely ignored the problem of pain" when they wrote about surgical procedures. Cohen describes a "purely technical instruction" for the removal of an arrowhead that has "no mention of sedation" and concludes that pain alleviation was "applied far more often in cases of illness or wounds" than during surgery.
So, what did that mean for Hal? I want to come back to the question of sedation, so I'm just going to focus on pain management of the wound for the moment.
Bradmore's account deals not just with the surgical removal of the arrowhead but with the management of the wound after. Implied, but not stated directly, is any care he did for Hal before he began enlarging the wound in preparation for the arrowhead's removal - I assume Bradmore spent some time devising his cure before attempting it and it's been suggested (I can't remember who by or find the reference offhand) that Bradmore may have been one of the "divers skilled doctors" who first tended to Hal at Kenilworth and attempted and failed to remove the arrowhead through the use of "potions and other cures" but, when writing his treatise, excluded himself from their number and thus their failure. Bradmore does note, however, that from "from the beginning of the cure to its end", his treatment involved an ointment known as unguentum neruale (or unguentum nervale) placed twice daily on Hal's neck which was then covered with a hot plaster.
Bradmore writes that this part of Hal's treatment was done "because of the fear of spasm, which was my greatest fear". Lang suggests this was a reference to tetanus. Michael Livingston, while not disagreeing with Lang's suggestion, also notes that the arrowhead was "embedded in bone bordering the sixteen-year-old’s brain" and notes the threat of "temporary seizures and even permanent neurological damage", regardless of what part of the brain was potentially affected. In other words, the spasm Bradmore feared may have been neurological, rather than tetanus. Livingston also suggests that the use of the ointment and plaster on the neck might be suggestive of where the arrowhead came to rest:
... the placement of the ointment and hot plaster upon the neck might well indicate that it was indeed at the base of the skull that the point had become lodged.
But let's focus on the ointment itself. Unguentum neruale was made up of "more than twenty herbs, with wax, butter, and some resins" and used for "'chilled nerves and sinews ... and for all cold causes". However, reading through Cohen's section on pain alleviation makes me wonder if it was also intended to have a pain-killing effect because Cohen notes that almost all medieval analgesics (painkillers) were external, used in salves and plasters, or (less commonly) for inhalation or fumigation, rather than being something to be ingested. Thus, unguentum neruale could potentially have been analgesic properties as well as the more treatment-oriented properties of reducing the risk of spasm and warming "chilled nerves and sinews". It does seem that a lot of medieval medicines served multiple purposes so Bradmore's statement that this was used to avert "spasm" doesn't necessarily preclude the possibility that it also had a analgesic effect.
Per Cohen, analgesic unguents could be hot or cold, presumably in the humoral sense, and "surgeons from the learned tradition preferred hot poultices", which would fit in with the description of it being used for "all cold causes". Bradmore also likely ensured that "that no cold air should be allowed near the patient" in his treatment of Hal, as he records on his chapter on spasms (n.b. I do not have a translation of his chapter on spasms).
I don't have access to the full recipe Bradmore to know what herbs were used to compare them against the examples Cohen gives (or to another reference) of plants used for pain alleviation to try and determine whether the herbs used had or were believed to have analgesic or anaesthetic properties.
Bradmore also mentions one other specific ointment used on Hal: unguentum fuscum, made up of resins and gums, which he claimed to use to regenerate the flesh. Lang notes the ingredients would have had a "mildly antiseptic effect" but no effect on regeneration of flesh (or, presumably, skin as Livingston suggests). Neither Lang nor Livingston gives any indication they could have an impact on pain. Again, I don't have the full recipe to try and determine whether some ingredients could have alleviated pain.
Bradmore does not mention using any ointments on or around the wound itself prior to the removal of the arrowhead. The tents he used to enlarge the wound were dipped in rose-honey, which would have kept the wound dry, delayed healing, prevented the tents from sticking inside the wound and had an antibacterial effect. After the removal of the arrowhead, the wound was washed out with white wine which would have had "a powerful, though shortlived, antiseptic effect" according to Lang. Then, for a period of 20 days, Bradmore used tents made of tow fibres with a cleansing medication made from white breadcrumbs, flour, honey and turpentine. The latter two ingredients would have had an antibacterial and antiseptic effect respectively. These tents were probably a precursor to modern wound-packing, which allow a deep wound to heal from the bottom up and mitigate the risk of infection by ensuring fluid and bacteria are not trapped inside the wound that has healed over at the top (i.e. skin level) but not the bottom of the wound.
Purgation, per Cohen, was also used as part of the health regimen and in some cases was believed to have an analgesic effect. This included emetics (inducing vomiting), blood-letting, diuretics, sweat-baths, fumigation and clysters (enemas). Bradmore doesn't make mention of using any of these on Hal but, iirc, he mentions it in another treatment. He may not have included it because purgation was a facet of basic health care that any surgeon would naturally not need prompting to perform and perhaps would be not be uniformly prescribed but tailored to the patient's needs and humours on a day-to-day basis. I suspect emetics were out due to the risk of aggravating the wound. Depending on how much blood Hal lost from the wound and the possibility subsequent blood loss (i.e. during early attempts to remove the arrowhead, when the wound was enlarged or the surgery to remove it), blood-letting may not have been seen as a necessity. If so, Bradmore's preferred methods of purgation would be the use of enemas, diuretics, sweat-baths and fumigations.
But then, what do I know? I'm not a medieval surgeon.
Though Bradmore is silent on Hal's pain, historians have often spoken of the pain Hal would have been in, often framing it as unimaginable or horrific. I have no doubt it was. As I've said before, the location of the wound would mean that even attempting to express that pain vocally or through tears would have likely added to the pain Hal was going through.
Livingston, in a more recent work, suggests Hal was given "ample doses" of Venice Treacle or theriac, "a closely guarded and very expensive concoction of 64 ingredients that included opium among its roots, leaves, barks, herbs, fruits, oils, and various other elements". Neither Cohen nor Lang make reference to Venice Treacle. However, the Middle English translation of Bradmore's treatise, changes Bradmore's recipe for the cleansing medication used during the wound-packing. The translator advised the use populeon instead of turpentine. Populeon was made of poplar buds or leaves, smallage, poppies, henbane, ribwort, brooklime, groundsel, watercress, deadly nightshade, black nightshade, plantain, pennywort, ribwort, tallow, lard and butter. Lang suggests this may have been intended to have a painkilling effect. However, the translator wasn't Bradmore so the use of populeon to manage Hal's pain must be doubted.
In terms of plants used to alleviate pain, Cohen notes that plants like poppy, henbane, crocus, hemlock and mandrake were not analgesic "since they put the person, rather than the pain, to sleep". These were very sparingly used as they "could just as easily kill the patient as anaesthetize the pain of surgery". Opium, due to the expense, "appears only in the writings of surgeons and physicians, but even these avoided it if at all possible". Cohen mentions at 14th century French physician and surgeon, Guy of Chauliac, who was only willing to use these plants when "all other painkillers had failed to arrest and the patient was in danger of dying from the pain". However, in such cases "one must use them only in suppositories for this method was safer than ingestion" and giving patients opium to drink was "even more dangerous". What influence Guy of Chauliac had on Bradmore, if any, and what Bradmore thought of the use of the stupefacients is unknown. But if Hal's wound was aggravated (and the pain was worsened) by the act of opening his mouth and/or swallowing, then using stupefacients in the form of suppositories rather than potions may have been the preference of both Bradmore and his patient.
On one hand, we can assume that Hal had the best medical care that money could buy. The cost of opium was likely no object and Bradmore (and any other surgeon or physician who attended) would have been eager to keep the Prince of Wales and heir to the throne as comfortable as possible. On the other hand, we can also imagine that they were very well aware of the warnings about the use of stupefacients and didn't want to risk accidentally killing the Prince of Wales through the use of a pain alleviating potion or plant that the literature was rife with warnings about.
Let's return to the question of anaesthesia. Some historians have referenced dwale or the use of "a basic anaesthesia, based on plasters of opium, henbane, laudanum or hemlock" (as suggested by Juliet Barker) when discussing Hal's surgery. Cohen notes that the "possibility of total anesthesia does crop up in various sources, but in no clear prescription".
A "soporific sponge" appears in various medical treatises from the ninth century on. In its earliest form, this involved a sea-sponge being soaked in opium, mandrake, henbane, and hemlock that had been ground together and mixed with water, then allowed to dry out. Theoretically, when about to perform surgery, the surgeon would re-moisten the sponge and place it under the patient's nose, where the inhalation of fumes would render the patient unconscious. To wake the patient, the surgeon would switch out the sponge for one soaked in "warm vinegar". However, as Cohen notes, "there is no evidence for any surgeon having used such a sponge". Guy of Chauliac heard of it and its ingredients but didn't have the quantities or recipe and warned against its use. It has been suggested that the sponge was "no more than a literary tradition", and Cohen agrees that its existence is unproven.
If not a sponge, was there another form of anaesthesia that Bradmore could have used? Cohen mentions a "very stubborn tradition" of an anaesthetic drink on the British Isles. In the twelfth century, there was "Letargion" or "the drink of oblivion" - the example Cohen cites is from the vita of St. Kentigern and provides no details of what it was supposed to be made of, much less how it was prepared or used. However, recipes for dwale, which Cohen describes as a "a milder concoction, containing minor quantities of hemlock, poppy, henbane and lettuce mixed with a gallon of wine" appear in several manuscripts, while John Arderne describes an anaesthetic ointment that is similar to the sponge in composition. Presumably, Arderne's ointment was what Juliet Barker was referring to. Cohen seems doubtful that these were anything more than a literary tradition and doubts they were actually used.
Cohen cites drawings of late medieval surgery that depicted surgical patients "tied down, held down by stalwart assistants, and thrashing and screaming with contorted faces" as being suggestive that neither the anaesthetic sponge, drinks nor ointments were effective - or if they were, so rarely used. They may have been a literary tradition. Cohen concludes that "there is no question that surgery under those circumstances were difficult for the surgeon but gravely traumatic for the patient".
As I said, I don't have a full translation of Bradmore's treatise to check for myself but neither Lang nor Livingston make reference to Bradmore including recipes that could have have an anaesthetic function in his treatise. He may have excluded them because, like other physicians, he distrusted them and/or considered the risks too great.
It's tempting to say that the delicacy of the work Bradmore had to do and the status of his patient meant that he was willing to try these unproven methods. But Bradmore must have been aware of the risks expounded by other healers and the potential disaster that awaited should his attempt to anaesthetise Hal result in accidental death. To me, it's the final point that's the deciding one for me. It'd one thing for Hal to have died as a direct result from the wound or during surgery, which would be understood and accepted as a risk and a potential outcome. It'd be another thing altogether for Hal to die because Bradmore used an experimental anaesthesia whose ingredients other physicians had warned about.
(I feel I need to emphasise here that I'm not saying that Henry IV would have chopped off Bradmore's head had Hal died of the result of the use of an experimental anaesthesia. I'm saying it would have had a devastating impact on Bradmore's reputation and career.)
I think the fact that Bradmore doesn't seem to include a recipe for or reference to anaesthesia is suggestive that he may have followed Guy of Chauliac (regardless of whether he knew Guy's work) and seen them as too risky or that Bradmore believed that the soporific sponge, Arderne's ointment or dwale would not work. Having said that and as I keep saying, I don't have access to a full translation of Bradmore's treatise so I could be wrong.
So, just how aware was Hal during the removal process and how did Bradmore prevent movement? Bradmore gives us no answers. I doubt full sedation was sought, much less achieved. I suspect that Bradmore used whatever methods of pain alleviation he had been using, perhaps increasing the dosage a little but still trying to keep it at a safe level. This likely involved an analgesic salve and perhaps a potion or suppository that included the dangerous stupefacients like opium, hemlock, henbane etc. I suspect Bradmore also restrained Hal, through the use of ropes and a "stalwart assistant" to keep him still. One hopes Bradmore was quick but the work must have been delicate and with little margin for error. Bradmore, frustratingly, is silent on the time frame for much of his treatment, including the actual surgery.
Were Bradmore and other surgeons sadists? Probably not. Medieval healers, Cohen says, saw "distinguished between different types of pain". Pain caused or signifying illness "required alleviation" but "pain that was part of the healing process required restraint and fortitude on the part of the patients. The healer was correct in inflicting it". Bradmore's concern in the case of the haemorrhaging carpenter suggests that he employed methods that were less painful in effort to avoid causing the patient more pain than necessary. It is also likely that very real concerns about the dangers of using stupefacients that could kill a patient as easily as sedate them for surgery played a role.
Like other surgical treatises, Bradmore's makes little reference to pain management or sedation
Bradmore's unguentum neruale possibly may have had painkilling properties as well as the warming effect intended to reduce the risk of Bradmore's greatest fear, "spasm".
Bradmore's care regimen very likely included purgation. I suspect emetics were unlikely due to the risk of aggravating the wound and blood-letting, enemas, fumigation, sweat-baths and diuretics were more likely, though blood-letting was likely sparingly used due to the blood loss Hal would have suffered at various points of his injury and its treatment.
Medieval healers were well-aware of the risks of using stupefacients like opium, henbane, hemlock, mandrake, crocus and used them sparingly. If any of these were used on Hal, this would have been known and the risk attempted to be mitigated.
This might have involved sticking them up in his ass instead of having him drink them.
Total sedation appears to have been a myth and it is unlikely Bradmore had a reliable anaesthetic on hand.
I suspect that Hal was given a safe dose of a stupefacients and restrained for the arrowhead's removal. I don't think he was entirely knocked out for it.
Juliet Barker, Agincourt: The King, The Campaign, The Battle (Abacus 2015)
Esther Cohen, The Modulated Scream: Pain In Late Medieval Culture (University of Chicago Press 2003)
S. J. Lang, The Philomena of John Bradmore and its Middle English derivative: a perspective on surgery in late Medieval England (PhD thesis, University of St Andrews, 1998) (this includes translations of Bradmore's case histories)
Michael Livingston, ‘“The Depth of Six Inches”: Prince Hal’s Head-
Wound at the Battle of Shrewsbury’, Wounds and Wound Repair in Medieval Culture, ed. Larissa Tracy and Kelly DeVries (Brill 2015)
Michael Livingston, Agincourt: Battle of the Scarred King (Osprey 2023)
