Abraham Lincoln's Blue Pills, Part I

Norbert Hirschhorn, Robert G. Feldman, and Ian A. Greaves

      This article first appeared in Perspective in Biology and Medicine (vol. 44, no. 3, summer, 2001), and is reprinted with permission from The Johns Hopkins University Press. The second and concluding part of this article will be published in the April issue of the SCR. The copious references that accompany the original publication have been omitted.
      Dr. Hirschhorn is a public health physician (retired), a poet, and a medical historian. Dr. Feldman is Professor of Neurology, Pharmacology, and Environmental Health at the Boston University School of Medicine. Dr. Greaves is Associate Professor of Environmental and Occupational Health, and Associate Dean at the University of Minnesota School of Public Health.

Abraham Lincoln's Clinical History Before 1861
      Consider a man in his fifties who has habitually ingested medicinal mercury; whose family and friends say that he demonstrates bizarre behavior and outbursts of rage, insomnia and forgetfulness; whose hands are seen to tremble under stress; and who, after ceasing to take mercury because it made him "cross," behaves like a saint under the greatest personal and professional duress. A clinician would most certainly suspect mercury poisoning. Such a man was Abraham Lincoln.
      Lincoln's personality, at least from the late 1830s, was one of rapidly shifting moods. Orville H. Browning, a close friend from the Springfield years and an astute observer, put it most succinctly: "He was sometimes jolly and genial, and again at other times absorbed and abstracted." These alternations, said Browning, were only part of Lincoln's "constitutional melancholy," but he emphasized that "both moods quickly passed away." By the 1850s, however, both the character and intensity of reported behaviors seemed to change. Lincoln's usual ebullience now alternated with an unshakable withdrawal from his surroundings and company, a behavior his contemporaries called "gloom," and observers described sudden outbursts of irrational or intemperate behavior.

      A young lawyer, Jonathan Birch, first met Lincoln in Bloomington in the late 1850s. His memoir describes Lincoln with near-photographic precision:

His eyes would sparkle with fun, and when he had reached the point in his narrative which invariably evoked the laughter of the crowd, nobody's enjoyment was greater than his.

The account then reveals the sudden turning of mood of which Lincoln was so often capable. "An hour later," Birch recorded:

. . . he might be seen in the same place or in some law office near by, but alas, how different! His chair, no longer in the center of the room, would be leaning back against the wall; his feet drawn up and resting on the front rounds so that his knees and chin were about on a level; his hat tipped slightly forward, as if to shield his face; his eyes no longer sparkling with fun and merriment, but sad and downcast, and his hands clasped around his knees. There, drawn up within himself as it were, he would sit, the very picture of dejection and gloom.

"Thus absorbed," commented Birch,

. . . have I seen him sit for hours at a time, defying the interruption of even his closest friends. No one ever thought of breaking the spell by speech; for, by his moody silence and abstraction, he had thrown about him a barrier so dense and impenetrable that no one dared to break through.

      Lincoln's sister-in-law Mrs. Frances Wallace, interviewed by Lincoln's law partner and biographer William H. Herndon, commented (in Herndon's paraphrase) both on the fixity and abruptness of mood change:

He was a sad man-an abstracted man . . . Lincoln would lean back-his head against the top of a rocking Chair-sit abstracted that way for moments-20-30 minutes-and all at once burst out in a joke-though his thoughts were not on a joke.

Lincoln's colleague on the law circuit, Henry Clay Whitney, once watched Lincoln "sitting alone in the corner of the bar, most remote from any one, wrapped in abstraction and gloom."
      According to Whitney, Lincoln's face grew ever sadder, even grief-stricken, and gave the appearance of despairing melancholy. Lincoln remained in what Whitney called "his cave of gloom" until he suddenly seemed to be "awakened from sleep." Whitney also clearly distinguished these dramatic changes in behavior from any ordinary turn of mien:

In his melancholy moods, the exuberant fountains of his pleasantry and mimicry were completely sealed and frozen up, but when the black fit passed by, he could range from grave to gay, from lively to severe, with the greatest facility.

      Witnesses testified to bizarre behavior and outbursts of rage. Whitney, who first met Lincoln in 1854, sometimes shared a room with him as they toured from one county courthouse to another. He described the following incident:

One morning, I was awakened early-before daylight-by my companion sitting up in bed, his figure dimly visible by the ghostly firelight, and talking the wildest and most incoherent nonsense all to himself.

Whitney said this was no unique event:

A stranger to Lincoln would have supposed he had suddenly gone insane. Of course I knew Lincoln and his idiosyncrasies, and felt no alarm, so I listened and laughed.

Whitney said he left the babbling Lincoln alone, for such behavior was not unusual, although Whitney conceded that "this time to which I refer was a radical manifestation of it." We may date this episode approximately, as Whitney said it took place in Danville, with Judge David Davis also along. Davis and Lincoln are known to have been in Danville together on May 8, 1857 and May 9. Herndon recalled similar behavior by Lincoln:

In one of his abstract moods he would to the observer's surprise without warning burst out in a loud laugh or quickly spring up and run downstairs as if his house were on fire, saying nothing.

Lincoln biographer Albert J. Beveridge interpreted Herndon's testimony to indicate that "time and again Herndon had experiences of the same nature."
      Biographer Michael Burlingame has fully documented a number of times Lincoln became memorably enraged in the years before 1861. Whitney was particularly struck by how readily Lincoln could become so angered that his face turned "lurid with majestic and terrifying wrath." In a graphic description, Herndon himself observed Lincoln in 1859 becoming "so angry that he looked like Lucifer in an uncontrollable rage." A singular episode was recounted by Ward H. Lamon (Lincoln's political operative, body guard and law circuit partner) in a posthumous memoir compiled by his daughter from his notes. In an 1858 debate with Stephen Douglas, Lincoln denied an accusation made earlier by Douglas that he, as congressman, had voted against support for American troops in the Mexican War. As Lincoln responded to the charge, Lamon recalled, "He gradually became more and more excited; his voice thrilled and his whole frame shook." Lincoln then reached over to Orlando B. Ficklin, who had served with Lincoln in Congress, took Ficklin by the coat-collar, back of his neck, and in no gentle manner lifted him from his seat as if he had been a kitten, and said, "Fellow-citizens, here is Ficklin, who was at that time in Congress with me, and he knows it is a lie." He shook Ficklin until his teeth chattered. Fearing that he would shake Ficklin's head off, I grasped Mr. Lincoln's hand and broke his grip.
      Insomnia, memory loss and subtle neurological signs are also common to mercury poisoning. Insomnia was observed by at least one observer in the 1850s, a young lawyer Lawrence Weldon, who wrote that the future president

. . . would frequently lapse into reverie and remain lost in thought long after the rest of us had retired for the night, and more than once I remember waking up early in the morning to find him sitting before the fire, his mind apparently concentrated on some subject, and with the saddest expression I have ever seen in a human being's eyes.

      Whitney was particularly struck by an episode of forgetfulness to recount it nearly fifty years later:

When he was running for the Presidency in 1860, I attended the great mass-meeting at Springfield, and going directly to his house, found him in the front yard watching the procession, which was then already passing, shook hands with him, and spoke briefIy. An hour later I returned and introduced a friend. After speaking to the newcomer, he seized me by the hand, and gazing at me peculiarly, said, "Whitney, I've not hold of your hand before." I corrected him, and he gazed at me with a dazed look, and said hesitatingly: "No! I've not seen you before to-day."

(Lincoln in the front yard would have been standing behind his fence, as a contemporary photo shows, and therefore unlikely to have had a distracting crowd about him.)
      Chronic mercury poisoning may also cause various kinds of nerve damage, both those visible to the clinician and those only detected by nerve and muscle function. A neurologist would first examine the way a person walks. Normally, one uses "position sense" to place one's feet in walking, heel-toe, heel-toe; a person with nerve damage from diabetes, alcoholism, or heavy metal poisoning can't quite tell where the feet are and walks with an exaggerated gait. Herndon has left some observations of Lincoln's gait tantalizing in their specificity:

When [Lincoln] moved and walked along . . . he put his whole foot down flat at once, not rising from the toe, and hence he had no spring to his walk.... He never wore his shoe out at the heel and the toe more, as most men do, than at the middle of the sole.

      Another a classic manifestation of mercury poisoning, tremor, was surely absent in 1865 when Lincoln chopped wood in a display for wounded veterans and then held the axe out at arm's length by the tip of the handle. But more subtle neurological changes, such as diminished motor speed and lessened dexterity, can be found immediately after mercury poisoning and may last years after the exposure. Such deficiencies could affect the control of a steady flow from an ink-dipped steel nib, especially when the writer is under stress. Herndon noticed something about an October 10, 1860 note to him from Lincoln, written during the heat of the election campaign: "The handwriting was a little tremulous, showing that L was excited-nervous." Only Herndon's transcription of the note exists, along with his comment. The campaign for president had been a time of great stress for Lincoln; a contemporary account reported that, "He was care worn & more haggard & stooped than I ever saw him.'' In another instance, on February 16, l863, a keen observer witnessed Lincohn's hand trembling while writing a letter. Benjamin Brown French, Commissioner of Public Buildings, wrote in his diary:

[The President] certainly is growing feeble. He wrote a note while I was present, and his hand trembled as I never saw it before, and he looked worn and haggard.

      (The letter in question, from Lincoln to Attorney General Edward Bates, is located in the National Archives, College Park, MD, RG204 Record 460. Our own analysis of the handwriting suggests shakiness but no evidence of an intention tremor.) Lincoln himself might have been aware of a tendency to tremor, for as he was about to sign the Emancipation Proclamation he worried that, with his arm "stiff and numb" from shaking hands at the New Year's Day reception,

. . . this signature is one that will be closely examined, and if they find my hand trembled, they will say he had some compunctions.

The observers were relieved to see his hand firm.

The Blue Pill: Prescription for "Hypochondriasis"
      Mercury was known to be poisonous as early as 2,000 years ago, but its main use as therapy began in the sixteenth century for treatment of syphilis. By the eighteenth to mid-nineteenth centuries, the popularity of mercury as a treatment for nearly every ill rose as medical practice degenerated. Thus one Dr. Thomas Dover (1660-1743), of Dover's Powders fame, prescribed blue mass for everything from "apoplexy to worms," for begetting children to curing tuberculosis. Calomel as a cathartic was also used to treat and prevent cholera, combined with bloodletting thought to "render the system more susceptible to the action of the grand remedy, Mercury." One disease in particular became a target for mercury-dispensing practitioners: the mental distress syndrome known as hypochondriasis.
      Hypochondriasis labeled a great sweep of mental and intestinal distress. "Beside Feare and Sorrow, sharpe belchings, fulsome crudities, heat in the bowels, winde and rumbling in the guts, vehement gripings . . . colde joynts, indigestion," is how Oxford scholar Robert Burton (1577-1640) described the condition in his compendium on mental illness, The Anatomy of Melancholy. Burton cited the prevailing wisdom that an obstructed liver was one of the principal origins of hypochondriasis, "the shop of humours, & especially causeth Melancholy." Burton explained that when ill spirits and humors troubled the soul, or "precedent diseases . . . distempered" a body, it became "clogged with an abundance of gross humours," which then had to be purged by laxatives and emetics. Otherwise,

. . . the Braine is still distempered . . . by vapors which arise from the other parts, and fume up into the head, altering the animal faculties.

      Whether it originated in the liver or in the brain, hypochondriasis was unquestionably seen as an ailment with true physical manifestations. A famed American physician, Benjamin Rush, wrote in his widely used textbook, Medical Inquiries and Observations upon the Diseases of the Mind: "It is true, [hypochondriasis] is seated in the mind; but it is as much the effect of corporeal causes as a pleurisy or a bilious fever." Rush recommended mercury as a stimulant to purge "morbid excitement" from the brain, as well as to remove "visceral obstructions."
      Another popular textbook of medicine was William Buchan's Domestic Medicine, published in twenty-two editions between 1763 and 1828. From the third edition of 1774 on, Buchan described hypochondriasis as a disease attacking men of melancholy temperament and

. . . brought on by long and serious attention to abstruse subjects, grief, the suppression of customary evacuations, excess of venery . . . [and] obstructions in some of the viscera, as the liver, spleen & c.

Buchan's recommended cure was to promote secretions with purgatives, with mercury first mentioned in the 1779 sixth edition.
      The diagnosis of hypochondriasis became a fashionable catch-all in the 1800s for a variety of baffling illnesses, many blamed on the liver. In an era of less-than-ideal hygiene there was surely a lot of hepatitis, and Britons returning from Asia and the West Indies also brought back bizarre liver and intestinal diseases. "Hepatic disease, although belonging more properly to a warmer climate, forms a large proportion in the class even of English maladies," stated one authority on hypochondriasis. The use of mercury to relieve hypochondriasis was based on the belief that mercury acted as an "alterative," by subvert[ing] diseased actions by substituting its own instead," and as a stimulative with

. . . increased activity imparted to all the secretory functions, particularly those of the salivary glands and the liver . . . a general excitement of the organic actions.

Physicians could see patients salivating profusely, but how did they know it stimulated the liver? What they noticed was the usual brown color of stool turning green, and they assumed that bile flow was being stimulated and obstructions relieved. Such observations convinced many medical authorities that mercury was a drug of choice, and they would not be dissuaded even when a contemporary, British physician George Scott, proved in 1859 that calomel did not increase biliary secretion in dogs. What actually was happening was that the antibacterial effect of mercury was inhibiting normal intestinal bacteria from converting green bile pigments to brown bile pigments-nothing more. Nevertheless, when in 1863 U.S. Surgeon General William A. Hammond removed calomel from the Union Army's pharmacopeia, calls for his cashiering came from all corners of the medical establishment.
      There were cautionary voices all along, and they proved correct. The eminent British physician and physiologist Thomas John Graham, writing in the 1820s, counseled that "the immoderate use of mercury" was itself a cause of hypochondriasis:

Calomel and emetics, when frequently repeated and long continued, cannot fail to aggravate and confirm the evil they were intended to cure.

James Hamilton warned that mercurial medicines could themselves produce "shocking depression of spirits, and other nervous agitations." The eminent Irish surgeon, Abraham Colles, described the consequence of prolonged use of mercury (as he deemed necessary for syphilis), a condition he called "mercurial erethismus," which produced "a great depression of strength, a sense of anxiety about the precordia . . . frequent sighing." ?

      The second and concluding part of this article will appear in the April issue of the SCR.