Abraham Lincoln’s Blue Pills, Part II

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 first part of this article was published in the February 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.

Lincoln Takes the Blue Pill for Melancholy/Hypochondriasis

An essay on Lincoln by Gore Vidal (1993), in which he quoted Herndon-“Mr. Lincoln had an evacuation, a passage, about once a week, ate blue mass”-first alerted the authors of this article to the possibility of mercury poisoning. Vidal accepted at face value that blue mass was merely some medication for chronic constipation; other historians, including David Donald in his recent biography of Lincoln, have followed suit. Only recently has any historian identified elemental mercury as the active ingredient, and then only in a passing footnote. In not realizing the identity of blue mass and the reason for its use, scholars have missed an opportunity to explore why Lincoln began taking mercury in the first place, and the potential connection between blue mass and Lincoln’s behavior, given mercury’s action as a neurotoxin. This historical oversight is all the more startling since Lincoln’s contemporaries knew exactly why he took mercury as a medicine.

When William H. Herndon, Lincoln’s law partner and biographer, said Lincoln “ate blue mass” (emphasis ours) he surely understood why. Lincoln suffered from melancholy (“black bile,” in humoral terms). As Herndon described it:

The most significant and noteworthy thing about him was his look of abstraction and melancholy. It was as painful as it was inescapable. I have often watched him in one of these moods . . . the most striking picture of dejection I had ever seen.

Lincoln’s melancholy “was a matter of frequent discussion among his friends.” John Todd Stuart, Mary Lincoln’s cousin and her husband’s one-time law partner and sometime political adversary, gave the melancholy a physiological origin in Herndon’s paraphrase of the interview held two months after the assassination:

Lincoln is a gloomy man-a sad man. Lincoln is-was a kind of vegetable-that the pores of his flesh acted as an appropriate organ for such Evacuations.

Whitney likewise related his discussion about the cause of Lincoln’s melancholy: “Stuart told me his liver did not secrete bile-that he had no natural evacuation of bowels &c. That was also a cause.” Ward Lamon, who knew Lincoln since 1852, acknowledged that “it would be very difficult to cite all the causes of Mr. Lincoln’s melancholy disposition,” but he emphasized “blue pills were the medicinal remedy which he affected most.” In his interview with Herndon, Lamon associated Lincoln’s hypochondriasis to the mercurial therapy: “[W]hen he had no passages he always had a sick head ache-Took Blue pills-blue Mass.” “Sick headache” was synonymous with “bilious headache,” that is, associated with the liver, and to be treated with the blue pill.

Stuart took credit for recommending blue pills to Lincoln just before the 1861 inauguration, saying “he did take it before he went to Washington & for five months while he was President.” But since Lincoln was away from his law practice for much of the time between 1858 to 1860 as he campaigned for high office, it is certain that Herndon and Lamon had noticed Lincoln taking the pills well before 1861. Another interpretation of the conflicting testimony is that the turmoil of the 1860 campaign prompted Stuart’s advice, and that Lincoln restarted a familiar medicine. In any case, Lincoln himself may have recognized the ill effects of mercury, as he told Stuart they made him cross.

In explaining Lincoln’s moods and use of blue mass, his friends were adequately describing Burton’s hypochondriasis and its accepted treatment. Lincoln himself knew about hypochondriasis and feared it. As early as 1837, when a young woman whom he had been diffidently courting was about to leave town, he wrote that the prospect of losing her “gives me the hypo whenever I think of it.” But hypochondriasis actually did hit him, and hard, on New Year’s Day 1841-which he remembered as “that fatal first of Jany”-when his engagement to Mary Todd was broken off. He was so distraught for several weeks thereafter that his friends feared he might even commit suicide. On January 20, 1841, Lincoln wrote urgently to John Stuart, now a U.S. Congressman: “I have, within the last few days, been making a most discreditable exhibition of myself in the way of hypochondriaism [sic].” Fearing his physician and friend, Anson Henry, was preparing to leave Springfield for better prospects, Lincoln implored Stuart to use his influence to have Dr. Henry appointed the postmaster in Springfield. The doctor, Lincoln admitted, “is necessary to my existence.” Given Benjamin Rush’s influence over medical practice at the time, it seems reasonable to suppose that the physician would have used blue pills to treat his patient. Recovery, however, was only gradual: a full year later, February 3, 1842, Lincoln wrote to his friend, Joshua Speed: “I have been quite clear of hypo since you left [January 3, 1842]-even better than I was along in the fall.” (Lincoln had rested for a month on Speed’s mother’s farm in August and September 1841.)

Besides hypochondriasis, there was perhaps another worry bedeviling Lincoln. At about this time, according to Herndon’s recollection five decades later, Lincoln wrote to the famous physician Vaniel Drake, then teaching at the Louisville Medical Institute, concerning the syphilis that, said Herndon, “hung to him and, not wishing to trust our physicians, he wrote a note to Doctor Drake.” The disease had supposedly been contracted in 1835 or 1836, Herndon reported, when Lincoln “went to Beardstown and during a devilish passion had connection with a girl and caught the disease.” We cannot know if Lincoln actually contracted syphilis, although the disease was not uncommon. However, while it would be exceedingly rare for secondary syphilis to recur four to five years after the initial venereal chancre, fear of venereal disease was typical of persons with hypochondriasis in those days, according to Dr. Rush. Daniel Drake was also widely consulted by those with hypochondriasis, and for this disorder he would offer the usual prescription of blue mass or calomel.

Recreating the Blue Pill

Physicians of the past who used mercury as a laxative to treat “bilious” and “melancholic” diseases believed that blue mass was milder than calomel because it caused less intestinal griping. What they didn’t know was that elemental mercury, especially in its vapor phase, binds more quickly to the nervous system than the salt, and would thus be more rapidly neurotoxic. It is true that elemental mercury as the familiar silver puddle is poorly absorbed by the intestine; but physicians and pharmacologists of the past pounded blue mass to such fine division as to eliminate any vestige of the silver drops, a process they called “extinction,” thus markedly increasing the surface area of the metal so that more metal vapor would gas off. As the authors of The National Dispensatory wrote,

All agree that the efficacy of the [blue mass] preparation is proportionate . . . to the degree in which the metallic globules disappear.

They considered the treatment had been “efficacious’’ if a patient salivated and had sore gums, sure signs that mercury had been absorbed.

The “blue pill” is actually a round, gray pellet the size of a peppercorn. We didn’t know this until we asked our colleagues at the University of Minnesota, Professor Cheryl Zimmerman and graduate student Kamran Askari, to reproduce it from an invariant nineteenth-century formula. It was simple enough to assemble most of the ingredients, which include mercury, liquorice root, rose-water, honey and sugar, and confection of dead rose petals. (In seeking the last item, they set the local florist to wondering if some strange cult happenings were at hand.) Our colleagues deferred to tradition and compounded the ingredients with an old-fashioned mortar and pestle, rolling the pills to their desired size on a nineteenth-century pill tile; but to accord with twentieth-century care and safety regulations, our colleagues insisted on surgical gowns, gloves, masks, and caps, and they worked under a negative pressure hood.

Their caution was well advised. To examine these pills as if they had been in the stomach, Dr. Wade A. Scheil of the 3M company, St. Paul, crushed two pills in sealed bottles with 250 cc of slightly acidic solution at body temperature. Mercury vapor in the air space of the bottles was detected semi-quantitatively by a Jerome 411 Gold Film Mercury Vapor Analyzer (Arizona Instrument Corporation), which is sensitive to as little as 3 mcg per cubic meter. The vapor from the pills registered off the top of the scale, at over 1.99 mg per cubic meter. The U.S. National Institute for Occupational Safety and Health (NIOSH) limits air exposure to 1/40 that level in any eight hours (Agocs 1992, p. 17). The same solutions were then passed through ultra-fine membrane filters with pores the size of molecules that can be absorbed directly through the intestine into the bloodstream. Dr. Scheil found that 750 mcg of mercury per liter of solution had come through the filter. The U.S. Environmental Protection Agency advises that one liter of water should contain no more than two microgranms of mercury and indicates that only up to 21 mcg of any form of mercury per day may be ingested by an adult without harm to health. The usual dose of blue mass was one pill two to three times a day, for a total of 130 to 185 mg of mercury-nearly 9,000 times the allowable amount if all were absorbed. Someone who “ate” these little pills would have seriously risked poisoning, absorbing both vapor and solid element.

Mercury and Its Effects on Humans

Despite the medicinal use of mercury for the past half millennium, it is only in the last few decades that the biology of mercury poisoning has become completely understood. Humans may be exposed to mercury in three chemical forms. Elemental mercury, whose vapor finds easy entry into the body through the lungs and skin, is the form mainly responsible for mercury poisoning in industrial accidents. Inorganic mercury, bound into salts with ions such as iodide, nitrate, or chloride; mercurous chloride, known as calomel or “sweet sublimate,” was once the most commonly prescribed form of mercurial medicine. Organic mercury bound to carbon compounds caused the horrific Minamata disease, when industrial discharge of mercury into the Japanese bay was converted to methyl mercury by microorganisms and passed up the food chain to be absorbed by humans with their daily ration of fish.

Regardless in what form or route it enters the body, mercury is eventually metabolized to mercuric chloride-“corrosive sublimate”-which preferentially binds to the central nervous system and kidneys; thus mercury’s toxicity is mainly revealed by neurobehavioral disorders or renal failure. Because mercury is excreted from the body only slowly, over months to years, one can suffer chronic poisoning by taking mercury in small, regular amounts that build up body stores faster than excreted.

Once mercury is absorbed, the signs and symptoms of poisoning are reliably predictable. In two reports Josef Warkany and Donald Hubbard described a total of sixty-eight infants and children in Ohio being slowly poisoned by calomel (then commonly used as a teething powder, laxative, and treatment for worms), or by mercurial ointments smeared on diaper rash. Four decades later, fifty-three adult men working in a chlorine factory in Tennessee were suddenly exposed to mercury vapor leaking from catalytic cells. Despite the vastly different conditions of exposure, the two groups suffered remarkably similar effects. About two-thirds of the patients in both groups became irritable, anxious, and hostile to the point of sudden rages and even violence; the adults also admitted to depression and forgetfulness. About twenty-five percent in each group had tremors or muscle twitching, and about one-fifth suffered insomnia. The children were more likely to lose weight, and they had that reddish blistering on the palms and soles peculiar to children poisoned by mercury, known as acrodynia, or “pink disease.” The classic signs of salivation and inflamed gums were seen in just twenty-one percent of the children and only nine percent of the adults. No patient had all the signs.

Emotional lability and hypersensitivity, collectively known as erethism, are typical and early signs of mercury poisoning; the word connotes reddening and flushing of the face. A description of erethism in a modern scientific paper on mercury poisoning brings Lincoln’s condition vividly to mind:

Mercurialism also manifests itself in an alteration of the emotional state. With an insidious onset, the mood generally swings toward the depressive side. Exposed persons . . . withdraw more and more from social contacts; they become increasingly irritable and sensitive, reacting strongly to relatively innocent remarks uttered by family and friends.

(Lest the reader wonder if Mary Todd Lincoln’s notorious tantrums were also a result of blue mass, they were not: in December 1869 she took the medicine, apparently for the first time, and had an immediate, severe reaction.)

It may be difficult for Lincoln historians to accept the possibility of mercury poisoning in their man, who by the 1850s already showed the remarkable qualities of character he would take to his presidency. But if, after his initial experience with hypochondriasis, Lincoln continued taking blue pills as self-treatment for a persistent constipation-melancholia complex, then the signs and symptoms his contemporaries described could readily have been due to a low level of poisoning known as “micromercurialism,” not incompatible with his persona.

Lincoln Stops Taking the Blue Pill

As the behavioral effects of mercury intoxication may be reversible, our clinical suspicion may be strengthened if we examine reports of Lincoln’s behavior after he stopped taking blue mass. If Stuart’s testimony is correct-that Lincoln stopped taking blue pills about five months after his March 1861 inauguration because they “made him cross”-this decision becomes one of the key reference points in the story.

Soon after his inauguration Lincoln was visited by a delegation from California seeking patronage. In the course of conversation, one member maligned a close friend of the President. At that moment, according to one observer,

The anger of Mr. Lincoln was kindled instantly, and blazed forth with such vehemence that everybody quailed before it. His wrath was simply terrible.

But while such an outburst had been typical of Lincoln in the previous years, the rages soon seemed to lessen and, indeed, vanish. Michael Burlingame comments on the White House years:

The remarkable thing about Lincoln’s temper is not how often it erupted, but how seldom it did, considering how frequently he encountered the insolence of epaulets, the abuse of friends and opponents alike, and the egomaniacal selfishness of editors, senators, representatives, governors, cabinet members, generals, and flocks of others who pestered him unmercifully about their own petty concerns.

What episodes of anger are documented seem to have been appropriate to the situation, and restrained. For example, in July 1861, a Union army doctor criticized Lincoln’s garb to his face, saying he resembled a Virginia wood-chopper. A witness recalled:

This unexpected allusion to his appearance was a little too much for the President. A little red spot of hectic red burned for a moment on his cheeks.

Nonetheless he replied pleasantly and generously. When in the summer of 1863, just before the fall of Vicksburg, Senator Wade of Ohio abusively castigated Lincoln for not firing General Grant, Lincoln turned him away with a deft verbal parry. Lincoln’s secretary John Nicolay said that day in and out for four years he was able

. . . to witness his [the president’s] bearing under most trying conditions and circumstances, and during the whole time never saw him manifest any extraordinary excitement . . . or indulge in any violence of speech or action beyond that of impressive emphasis.

Another of Lincoln’s young secretaries, William O. Stoddard, opined that “To say that [Lincoln] now and then gave way to short-lived fits of petulance is but to admit that he was human,’’ but he records in his entire biography only one unremarkable “fit of petulance”: when a Union officer told Lincoln in February 1862 that no advance was possible because the pontoon trains weren’t ready,

Lincoln retorted, “Why in hell and damnation ain’t they ready?” [and then] resumed the work before him, but wrote at about double his ordinary speed.”

Later that fall, an unanswered raid by “Jeb” Stuart into Maryland and Pennsylvania vexed Lincoln who, according to Nicolay, “well-nigh lost his temper over it,” but restrained himself. Attorney General Bates found a moment of temper in September 1863 remarkable enough to record in his diary: “The Prest. was greatly moved-more angry than I ever saw him.’’ Josiah Holland, one of Lincoln’s earliest biographers, did note that Lincoln became more “peevish” and “querulous” as the war dragged on. But Holland’s adjectives described an anecdote about a persistent lady who wanted Union hospitals for the wounded established in the north. While Lincoln was clearly irritated by the challenge to his avowed policy-he feared more deserters the closer to home-he encouraged the supplicant to return, and in the end conceded the point most graciously. Holland was comparing Lincoln’s occasional sharp retort to what Holland regarded as his perfect equanimity in debates with Douglas (but see Lamon’s eye-witness recollection above), and against the demigod status Holland predicted Lincoln, like Washington before him, would acquire.

Nothing in these mild episodes is comparable to the towering rages described by other observers in the 1850s, or their accounts of strange behavior. Even the deep melancholy and unassailable “cave of gloom” seemed to disappear: Nicolay’s daughter Helen, working from her father’s extensive notes, related that,

Gradually under the strain of responsibility and care, [Lincoln’s] demeanor changed. He was just as cordial, just as kindly; but his infectious laughter was less often heard; and from brooding on serious and weighty things he acquired an air of detachment. “Lincoln’s prevailing mood in later years was one of meditation,” my father wrote.

Clearly different from what Whitney and others reported in the 1850s, but similar to O. H. Browning’s description, which we take to be from the 1840s, a French diplomat recorded facile changes from laughter to sadness and back to a

. . . generous and open disposition. . . . In one evening I happened to count over twenty of these alterations and contrasts.

However, an obvious weakness in comparing pre- and post-White House observations is that we have, to our knowledge, only Ward Lamon reporting from both perspectives.

Conclusion

Another difficulty with our hypothesis of mercury intoxication is not knowing precisely when Lincoln took blue pills, in what quantities, or even where he procured them. Ledgers and day books from the Corneau & Diller Drug Store in Springfield spanning the years 1849 to 1861 show that 245 medicinal and sundry purchases were made by the Lincolns, including eight purchases of brandy. Of this total, only five were unspecified pills and four were calomel. No specific mention is made of blue mass or blue pills, even though mercury in this form was dispensed to other patrons. It is conceivable that one of the proprietors, Roland Diller, Lincoln’s close friend and political ally who lived but a block away, was providing blue mass “off the books,” since opprobrium would have been attached to the diagnosis of hypochondriasis in a person who aimed for high public office. Another private source could have been Mary Lincoln’s brother-in-law and physician, William S. Wallace, who had been a co-owner of the same drugstore from 1839 to 1849. Of course, Lincoln may have obtained blue mass from druggists in other towns while on the law circuit. Records show that he obtained a medication from a pharmacy in Ashland on the Beardstown-Springfield road sometime in the early 1850s that may have contained mercury: H. O. Brownback, great-grandson of the physician and founder of Brownback Drug Company, still has a prescription written for Abraham Lincoln but believes patient confidentiality rules against its publication. In a letter to one of us (N. H.) dated 21 August 1996, Dr. Brownback wrote:

The fact that Lincoln chose to seek medical and pharmaceutical care outside of his immediate community certainly acts to heighten our sense of responsibility in the matter. While I sincerely regret that I am unable to further assist in your research, I do advise that the various mercuric compounds were common ingredients in many mid-nineteenth century prescriptions.

The strongest evidence that Lincoln found his own sources for medicine comes from a letter dated April 3, 1861, from Samuel H. Melvin, a physician and owner of the largest medical and pharmaceutical supply business in Springfield:

Hon A. Lincoln Washington City DC

Dear Sir

I only arrived at home this morn-having been detained in Ohio longer than I expected. I now hasten to send you the Pills as requested. I send you 5 boxes made by Mr Canedy and one box of my own manufacture.

“Mr. Canedy” is identified as Peleg Coffin Canedy, a Springfield pharmacist and “friends with Abraham Lincoln.”

Could a retrospective diagnosis of mercurialism be made from a sample of Lincoln’s hair? A single dose of mercury clears from the blood within a few days, moving on to other parts of the body. Mercury in the hair thus reflects the blood level at the time the hair root is forming. The mercury is chemically bound to and moves up with the growing shaft. As hair grows at about one centimeter a month, approximately five inches per year, mercury in the top centimeter of a moderately long hair reflects mercury ingested a year before; more recent intake would be seen in hair closer to the scalp. The specimen at the Museum of Health and Medicine in Washington, D.C., is said to come from Lincoln’s autopsy, and thus unlikely to be revealing if Lincoln gave up blue mass in 1861; any mercury in this sample would reflect intake in 1865 because Lincoln had a near crew-cut two months before his death.

If blue pills prompted Abraham Lincoln’s remarkable behavior in the decade before he went to the White House, then his insightful decision to stop taking them may have been crucial to the outcome of the Civil War. Imagine a President Lincoln impaired by the bewildering effect of mercury poisoning while trying to cope with political intrigue, military reversals, the incompetence of his generals, and his own personal tragedies. His calm steadiness was at least as necessary in preserving the Union, it may be argued, as battlefield decisions, military appointments, or political strategies that history records as important for the success of the Federal cause.