PARANOIA IN TWO SISTERS. BY .FREDERICK PETERSON, M. D., New York City. Reprint from The Alienist and Neurologist, St. Louis, January, 1890. [Reprint from the Alienist and Neurologist, January, 1890, St. Louis.] PARANOIA IN TWO SISTERS.* By Frederick Peterson, M. D., Pathologist to the New York City Lunatic; Asylum Lecturer o i Nervous and Mental Diseases at the New York Polyclinic and Vanderbilt Clinic. r I 'HE simultaneous development of insanity in two or more persons associated together, or the imposition of delusions gradually arising in the mind of one upon the impressionable intellect of a second, third or of many persons, has been described under the names folie a deux, folie simultanee, reciprocal insanity, folie impose, etc. There are several factors which govern the evolution of such insanities. In both forms a degenerative soil is usually required for the proper germination and growth of morbid ideas. In the simultaneous variety there must be, in addi- tion to predisposition, that similarity of intellectual sub- strata, which we find particularly in persons who are blood relations or who are intimately joined together by mutual like and dislike; hence it is that brothers or sisters most frequently manifest simultaneous insanity. Take two healthy children of one family and bring them up far apart, yet there will be innumerable physical resemblances between them, and many peculiarities in their character and conduct which prove them to be con- sanguineous ; if a hereditary instability of nerve-cells had been implanted in them, there would be a tendency to a similar form of dissolution, even if they remained apart. How much greater would this be in two persons so intimately associated as sisters for instance. In children the study of unconscious imitation is one of great inter- est. Who has not observed the identity of intonation of phrases, of gesture, of laughter, of many facial expressions, of certain habits, in children either related or brought up • Read before the American Neurological Association, at Long Branch, N. J., June 25th, 1889. 1 2 Frederick Peterson. together? Such unconscious imitation, as is well-known,, may lead in children to the contraction of certain nervous and even mental diseases. The contagious quality of emotions is well established. An explosion of laughter will call up smiles on even melancholy faces in a crowd. A pathetic scene on a stage will bring tears and depress- the oral angles in a large audience. The unconscious imitation of gestures, such as bowing, often seen in adults, is in a milder degree such mimicry of motion as is- observed in dancing mania. Another element in the imposition of insanity by one upon another is the quality of the morbid mind-product. If a delusion, it must have an air of probability to the person receiving it, and must be gradually developed and imposed. It is because suspicion is inherent in the nature of most people, because suspicion can wear so much prob- ability of truth that persecutory delusions are by far the most frequently adopted by others. Credulity is an important factor in the imposition of insane delusions upon others. It was the ready credulity of large num- bers of people, especially as regards religious subjects, that in the past has led hundreds of thousands of people to adopt with faith the delusions of paranoiacs like John of Leyden, John Thom of Canterbury, Joan of Arc,. Richard Brothers, Joanna Southcott, John Brown and many others, and actually to sacrifice their lives upon the altar of their beliefs. Though these delusions emanate from an insane pefson, their acceptance by others does not, of course, necessarily imply insanity in the latter, for delusions of this character have their support in the superstitions of people and in their ignorance concerning supernatural matters. A persecutory delusion might be imposed by an insane person upon an intimate associate, and yet the latter need not of necessity be insane; but when the exposed individual adopts the delusions, regulates his conduct upon them, allows them to become rooted in his mind, even begins to share the hallucina- tions of his friend, there is, of course actual aberration Paranoia in Two Sisters. 3 •of mind present. Four cases of folie a dezix have come under my observation. One case was that of two sisters, aged about 50 to 55, Irish, washerwomen, who living alone by themselves in a tumble-down shanty, were often tor- mented by boys throwing stones at the house at night, and otherwise teasing them. They finally developed per- secutory delusions with hallucinations, and both were very much alike. They became so violent in their demonstra- tions, that ere long both were taken to the asylum, where I took charge of them. They were separated, the result being that one became rapidly demented and the other became a quiet worker with fixed persecutory ideas and auditory hallucinations. Another pair of sisters, colored, between 40 and 50 years of age, living in New York, are similarly affected. For ten years one sister has been a paranoiac with delu- sions of persecution by means of electricity, which is at all times, night and day, hurled through her body by a vast or- ganization of conspirators. She has hallucinations of hear- ing. The sisters have not lived together until within six months, the sane sister having recently become a widow. The sane sister is gradually adopting the delusions of the insane one and probably the hallucinations. She believes her sister is persecuted by an organized band of conspirators with electrical appliances, but has not as yet that idea with regard to herself. A third case was that of a husband and wife, who both became typical cases of melancholia, with, of course similar delusions, one shortly after the other. Such a case as this might be called a coincidence, and not an imposed insanity. Probably grief over the insanity of the husband was one factor in developing that of the wife, but uncon- scious emotional imitation between two persons united by special bonds of sympathy was undoubtedly another •element. The fourth example I believe to be one of simulta- neous insanity. It is the case of two sisters living at 'present in New York City, and I shall proceed, with their 4 Frederick Peterson. help, to give an account of their mental infirmities in detail. C. K. and H. K., now respectively 36 and 42 years of age, teachers of music and singers by occupation, of German parentage, and have both been insane some ten years. Their mother was a case of paranoia with fixed delusions of an exalted religious nature. She believed herself to be the mother of God. She was never in an asylum but lived at home until her death. While insane she gave birth to the younger of the two sisters, C. K. The following sketch of their history written by C. K., one of the sisters, in December, 1888, when I first saw them, will throw light upon their mental peculiari- ties : " Many years ago my mother, through the persuasion of my uncle and aunt, emigrated here with her two sons and three daughters. My father, teacher of music and languages, had died in the old country about ten years previous to our coming here. Trouble came immediately through our uncle, a missionary, residing in Brooklyn, who tried to influence the elder brothers and sisters to think mother was queer; so that we were very soon scattered about. Even my mother, through ill treatment, left the house, and I, only five years, was put by strangers. My eldest sister accepted a governess position. * My brother, utterly discouraged, was compelled to take any work he could get. * * * Here it already shows my uncle's hypocrisy, as he went to the family where my sister was, slandering my brother most viciously. * * * My younger brother had been placed in an institution by the influence of uncle. * * * My oldest sister married five years afterward, and eight years later my mother died. My sister H. and I then became teachers in a school, but were called home at the close of the term by the illness of my married sister. She died in three days, leaving two children, two having died previously. One of the children died four weeks after my sister's death. * * My brother married and asked us to live with him. * * * While with my brother there was trouble with his wife's family from the first day. My sister-in-law already then often said she would put a stop to that music yet, tried her utmost to set my Paranoia in Two Sisters. 5 brother against us. * * Often left without my breakfast, thought would end my life by drowning myself, for had never thought human beings could be so vicious. Our stay with them became such a torture that finally concluded to make a change. * * * We started a private school. * * * Were unsuc- cessful with the school, as there were already too many in the neighborhood. * * A professor, of whom I had already taken instructions, asked me to take a solo in a cantata, and with three days' notice, many said that I rendered admirably my part, for among forty voices, mine was considered the strongest and sweetest. My sister also was successful in church music. Strangers congratulated us, but our own never said a word. My sister obtained a school position, and I commenced giving piano lessons. * * * My brother-in-law and a friend of his, Mr. R., would seek out our acquaintances and try to run us down. Mr. R. wrote to our landlady that we could rest assured that every step of ours would be traced. Thus things went on. It seemed every time when we were just at the point of making an application for a singing position would get sick, for as long as my brother has been married, have been sick with the excep- tion of four months. My sister's health became miserable, so that she had to resign her school position. We employed doctors, our health being wretched. * * We thought it expedient to move from Brooklyn to New York. So we found rooms in 53d street, where we remained only three months, when we moved to 57th street, thence to Beekman Place, from here to 2d Avenue, where we hoped to be comfortable for the winter. Was visited here by our sister-in-law, which reminded me of the expression she used when at her house. She often said : ' I'll put a stop to that singing or music yet! ' From here moved to an old acquaintance in Monroe street. Although our health was poor, we spent here some pleas- ant hours. Have every reason to believe our brother-in- law interfered, and have sufficient proof that he inevitably must have had secret intercourse with our uncle. He knew we were competent in singing, for Dr. Damrosch, while trying my voice, several times remarked, ' Wonderful! you must be an American,' for I swelled high C most artistically. * * All this time we had been con- stantly under the doctor's treatment. Moved to 41st street in 1880, where we remained nearly four years. In 6 Frederick Peterson. i88l, the doctor being discouraged, said he could not do anything more for us. We therefore commenced taking an advertised medicine. Our improvement was so rapid, and felt so happy that we thought we would at last be able to succeed, but it only lasted four months, for upon imparting it to a few friends and relatives we grew immediately worse. Thus time passed on and my brother complained in all his letters of not feeling well, also that he had been poisoned. Naturally we felt very badly. So I decided to call upon my sister-in-law; of course feared nothing from her, as I knew she had wronged us. * * So after a few weeks we called there. In the course of conversation, she suddenly remarked, ' My husband had to give those papers of your mother to Mr. S. to copy, and I shouldn't wonder if something would come soon.-Yes, I am sure it will. She had not more than expressed, when she almost fell back and exclaimed. Oh, if 1 only had not told you ! 1 should not have told you ! ' Thereafter, whenever we asked our brother about the papers, he said he knew nothing about them, that we knew more than he. r * * I remember that whenever I had been at my sister-in-law's house, next day would have swollen limbs. * * * On account of sickness went boarding. First few days improved, but suddenly became so sick (in warm weather my finger- nails turned purple) that we made a speedy change by taking a room again. Took a floor in W. 51st street, but when our things arrived there the doors were locked and we were compelled to seek shelter for the night at my brother's house. * * * Well, we took another floor, but after being there only about six weeks decided to move again, and went to E. /2d street. * * * Here just before Christmas my brother brought a can of maple syrup, of which both of us together had not taken a half-pint, when we felt wretched. As we thought the syrup looked strange, my sister asked the opinion of a druggist who said he thought there were worms in it. * * * For the past four weeks not a bit of heat had come into our room, even when they had a rousing fire, but the last night we were there the register was hot enough to burn ones fingers. Had the windows not been opened wide undoubtedly we should have smothered. Moved to 2d ave. and 51st street. Had a chemist analyze the syrup in May; he pronounced it criminal. * * We had reason to- Paranoia in Two Sisters. 7 believe it to be a conspiracy; they want us to be cripples or dead. * * One Sunday our rooms were wholly filled with camphor, which stupefied us, but by taking medicine and going out, we just managed to keep awake. The same evening, when they thought we had retired, but being already prepared by taking medicine to keep us awake, the atmosphere in our rooms became scented, as though we had the choicest flowers. The family not having any such flowers in their garden, knew something was wrong, remained in a swoon for about three hours, tried our utmost to get on our feet to take another dose of medicine. * * * I undoubt- edly would have had success in elocution ; but I had no more than commenced when my body became perfectly deformed. Our condition became so terrible that we called for Mr. O., who after seeing us said he would find someone to do something for us. Then moved to E. 74th street, where our sufferings continued to such an extent that several mornings we arose looking almost black. * * From here removed to E. 65th street, where terrible things happened Our faces became so disfigured that we were compelled to fly to Brooklyn. We had to wear bandages on our faces for the past six months. Later we had to go to New York again for a few weeks in order to escape the worst. Upon our return it was the same. Would go out all day wandering about, coming home in the evening refreshed ; as soon as in the house felt choked. Again moved in August. Here have been suffering constantly. Whenever we go through the halls with our faces uncovered, receive terrible blotches of an exceedingly painful nature. Cannot sleep without covering our faces with wet cloths, nor dare we trust our- selves to be in our rooms without having our windows open. Thus if protection is not given us soon, although they might for a short time cease doing anything, they will make it unexpectedly worse. It stands to reason that if capa- ble of doing such vicious things it could be done in such a light form that it would perhaps hardly be notice- able, yet could be just as injurious and even worse than before. " Having read the enclosed you will perceive that it is a dreadful affair. We shall never have any peace so long as their power continues. We are absolutely excluded from everybody. We cannot even go to church. Whenever we have done so, we grew worse." 8 Frederick Peterson. From a collection of twenty-five letters written by H. K., since the drawing up of the autobiographical sketch by C. K., I make some further extracts which bear upon their delusions and conduct. The majority of these letters were written to Miss Nellie Bly, of the New York World: "Having read so much of your benevolence for the welfare of humanity, I take the liberty to appeal to you, and request you to have the kindness to do something for us. It seems to me you will perhaps be the only one able to detect and unravel something that has so far appeared a mystery to others. We are two sisters, have taught and studied music, and gave music lessons, have been terribly persecuted for fifteen years, and are yet. * * * We have reason to believe there is a detective in this house." {Nov., '88). " Everywhere we live tricks are played on us to make us unfit to do anything. Do you think that such vicious- ness is right or should be tolerated in a civilized city ? " {Dec., '88). "From the first have been annoyed with various kinds of injurious smoke, which stopped immediately upon inform- ing the landlady. * * * Qn account of notic- ing peculiar actions, resolved to watch one evening, and from what we saw, have reason to believe that either there is an expert or the parties in the house have been bought to do these tricks. Next morning after watching, the lady from above stood right in front of me when entering the room, and after a short time noticed that my eye had received a terrible blotch. Also caught her listening several times at our door. This lady in the beginning had brought us flowers, of which the scent of the first bouquet seemed so unnatural that we placed it outside of the window. The day the last bouquet was brought we deemed it advisable to wrap it in paper. * * * About four weeks ago we pasted up a certain door from which smoke issued. There was apparent relief, but after a few days noticed that our clothing closet had such a peculiar odor that we were afraid of wearing anything ; whereupon we had every crack filled. The day following our interview with you, at 4:30 P. M., suddenly a strong cigar smoke came into our room, which had the effect of making us sense- less. Upon inquiry down stairs ascertained that no one in the house was smoking nor had been since morning. * * * We find we are choked nights, and have Paranoia in Two Sisters 9 discovered open spaces in the ceiling and in another door. {Jan., '89.) " Suppose you think it strange that we have not yet moved from Brooklyn. * * Assure you it is no easy matter to make a change when certain of being followed. My sister has had to endure- a great deal, for her face is all disfigured; also mine is bad enough. * * * They only look out for a good chance to do their mis- chief, for we know them too well by this time and under- stand their scheming." {April '89^ " We shall not be able to stand these smokes. What can be done? Our whole room has not been free from the same this morning. Our headaches are terrible. I assure you we will be ruined. Fear very much that we shall have to take the worst step. Pardon haste. Have moved with much difficulty to W. 48th street in New York." {April, 1889). " Both of us have received new blotches again. They intend to disgrace us wherever we live, by compel- ling us to wear bandages. * * * There must be an instigator in the house, perhaps two or three, who sets all whom he can against us. They throw something at our faces." {April, 1889). " A discovery we made last evening, about a quarter to IO o'clock, which we think ought to bring everything to light, if only an authority was sent in a secret way to watch, might be perhaps done by sending a smart boy, whom no one could humbug. My sister happened to put her head under the wash-tubs when she suddenly exclaimed, ' What a horrible smell of smoke! ' I per- ceived the same. * * * This work has been going on for four years. * * This is then what makes us look so horrible. They are all sorts of smells combined with a chloral, to bring about the desired symptoms. * * * Constantly someone seems to be around, especially upstairs, working with tools all over their rooms, as if making spaces between the wood- work separating it. * * * They are hammer- ing so softly. They must have a machine by which they can hear and perform at the same time. * * * One evening my sister washed her hair in the water, and it all fell out and has never been the same since." {May, 1889}. " Assure you our persecutor is here again. This morning when we arose our whole room was filled with 10 Frederick Peterson. a fumigated candle smell. They are doing everything and anything to cause weakness and headaches; besides they throw stuff on us which form spots very painful, like corns. * * * They evidently chloroform us, for since we have been here we have had the feeling as though we should fall in a swoon. * * * They put something in the water, for it smelled and tasted horribly. * * * Wanted to go to police headquarters and make complaint, but thought it best to ask you first." ^June^ 1889). We have here accounts of their disorder from both sisters, an autobiographical sketch from one, and a series of letters from the other, which together show the identity of their morbid mental phenomena. The instigators of the conspiracy against them are chiefly their uncle, brother-in- law and sister-in-law, and a brother has also been inveigled into it. By them are employed numerous detectives, expert chemists and handicraftsmen, and as they have privately hinted to me, also many lawyers. Openings are made in their rooms in spite of all they can do, for the insufflation of noxious gases, smoke, camphorous, chloral and chloroform vapors, and by some unseen agency substances are thrown at them which produce painful cutaneous eruptions. Their food and water and heating apparatus are tampered with, for the introduction of poisons or to produce serious illness. They hear the mechanics at work upon the floors, walls, ceilings, and the voices of the detectives-hallucinations of hearing. Their food has a peculiar taste-hallucinations of taste. Most prominent of all are the singular odors of the room, of food and flowers sent them, of the water-halluci- nations of smell. Sometimes they are black in the morning when they look in the mirror-illusion of sight. They are subject to remarkable, generally painful, sensations in their bodies-hallucinations and illusions of cutaneous sensibility. They hint of imaginary property in Germany, out of which they are being defrauded by relatives. For ten or twelve years they have been driven from one place to another in Brooklyn and New York by their pursuers. As yet they have sought only escape and protection from Paranoia in Two Sisters. 11 persecution; they have very rarely manifested anger, by pounding the floor when hearing the mechanics at work,, or by complaint to the landladies, and have not been brought to bay, to a condition in which they might turn upon the actual instigators of the conspiracy and do them bodily harm. They have been on the point of a visit to po- lice headquarters to make declaration against their enemies, and it will be some such climax as this that will probably, ere long, eventuate in their incarceration in an asylum, From what I can learn of their history in youth the two girls differed from others of their age in a slight degree, some trifling eccentricities and some over-weening self-consciousness constituting this difference. They have always been closely united, living together, sleeping together, having the same affinities, talents, pleasures and pursuits. The development of suspicions and delusions of persecution had been so gradual that it did not become evident to others that they were actually insane until a comparatively recent period. When I first saw them in my office, they came heavily veiled, and upon removing their veils, their faces were patched all over with small square pieces of cloth covering sores. These were only an ordinary acne, made much worse by picking, by wearing wet cloths on their faces all night for the purpose of preventing poisonous vapors from entering their lungs, and by the removal of the strongly adhering pieces of linen from the bleeding surfaces. The scars of some of these sores may be observed in the photographs.* They healed up rapidly when I had prevailed upon them to make use of ung. zinci freely. It will be seen that they have insane physiognomies. The face of the younger is particularly characteristic of a degenerative type, one of its features being a disagreeable prognathism. There are differences between the two heads cephaloscopically, but no great asymmetry. The cephaloscopic drawings are not here reproduced, as the variations of the heads are sufficiently evident from the figures given. The following is a table • 1'n; puot are not reproduced here for obvious reasons. 12 Frederick Peterson. of measurements of their heads, made according to the scheme described by me in " Some of the Principles of Craniometry " (iV. Y. Medical Record, June 23, '88), and which I am in the habit of using for all cephalometrical purposes :* purposes :* Normal female Head Average of adults, in Head of Head of centimetres. C. K. H. K. Circumference, - 53- 53-5 52.5 Volume (empirical), - 13.00 13.10 12.87 Naso-occipital arc, - 34- 34- 34- Binauricular arc, - 34- 32.5 33- Antero-posterior diameter, - 18.2 18.9 18.5 Greatest transverse diameter, i5- 14.2 14.5 Length-breadth index, - 83-8 76.7 78.3 Binauricular diameter, - 12.6 11. 11.8 Empirical greatest height, - 12.8 13-5 12.9 One is dolicocephalic and the other is mesaticephalic Although some of the measurements are below the nor- mal average for women, a few are above. There is the slightest tendency to leptocephalus, and the binauricular diameter in C. K. is even pathological, as it is outside of the limits of physiological variation (li.6-14.6), and that of H. K. is very near the lowest limit. The greatest transverse diameter is also considerably below the normal average and very near the physiological boundary line (14-17.5). It is, of course, somewhat difficult to decide accurately whether this example of folie a deux is one of simultaneous or of imposed insanity. The fact that C. K. was born during the insanity of the mother, and exhibits a more characteristic physiognomy and a more marked atypy of head, might lead to the supposition that she was the first to be affected, and had by gradual mental contagion, affected secondarily her older sister. But to me it appears that it would more properly be designated a form of reciprocal insanity, folie simultanee, and I feel sure that even if they had been separated from the age of twenty a paranoia would have developed in each in the course of the subsequent decade. •See also "Cranial Measurements in Twenty Cases of Hemiplegia Spastica Infantilis,'' N. Y. Medical Journal, April 6, 1889.