The Journal of Psychology

ISSN: 0022-3980 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/vjrl20

Rorschach Evaluation of the Schizophrenic Process

Following a Prefrontal Lobotomy

Ralph O. Van Waters & Jerome G. Sacks

To cite this article: Ralph O. Van Waters & Jerome G. Sacks (1948) Rorschach Evaluation of the
Schizophrenic Process Following a Prefrontal Lobotomy, The Journal of Psychology, 25:1, 73-88,
DOI: 10.1080/00223980.1948.9917363

To link to this article: http://dx.doi.org/10.1080/00223980.1948.9917363

Published online: 02 Jul 2010.

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 Published as a separate and in T h e Journal of Psychology, 19+8, 26, 7 3 - 8 8 .

R O R S C H A C H E V A L U A T I O N OF T H E S C H I Z O P H R E N I C
PROCESS F O L L O W I N G A P R E F R O N T A L
LOBOTOMY*
Bosion, nfassarhusetts

RALPH 0. VAN WATERS A N D J E R O M E G. SACKS

(In collaboration with Paul G. Myerson, M.D.)
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A. DESCRIPTION
OF T H E EXPERIMENT

In this paper we shall describe the case of Edward, a 17-year-old boy

who had undergone lobotomy at age 16 years three months and was referred
by one of the writers (the psychiatrist) for a Rorschach evaluation which was
not t o be based upon any known facts from clinical or social history save
the single fact that the patient had undergone bilateral prefrontal lobotomy
on the 12th of June, 1946. Hence, extramural adjustment prior to his
operation was not known and could have no influence upon the evaluation
itself. T h e Rorschach examination was conducted on the 29th of March,
1947.
We shall present the actual responses of the subject to the 10 Rorschach
cards, the quantitative results, and an evaluation. T h e psychiatric history
will follow. W e will describe the relation of our findings to Rorschach
“organic signs” and psychological sequelae described by research workers
dealing with cases of bilateral prefrontal lobotomy. From this we shall indi-
cate the hazards of predicting subsequent adjustment on the basis of the
Rorschach results unless the preoperative condition has been assessed and
verified.
B. RORSCHACH
FINDINGS
ON EDWARD

1. Responses
a. CARD I : Reaction Time 27”, Total Time 10’.
(1). Main.
“I believe this would be the power of wrong overcoming the power of
good and . ..believe the good is slowly dying out while the evil power
is becoming more powerful.
“The reason I say this is that a mythical character ( I n q u i r y 1 ) is
holding two vultures ( I n q . 2) over the body of some woman ( I n q . 3 )

*Received in the Editorial Office on September 2, 1947, and published immediately

at Provincetown, Massachusetts. Copyright by T h e Journal Press.
73
 74 J O U R N A L OF PSYCHOLOGY

and the woman is trapped all around by these powers. T h e r e is no

means of escape for her and it would do h e r no good to escape unless
the power of good can find some means of developing so that the
power of good will predominate. T h e two figures representing the power
of evil a r e shabbily dressed and the color of their clothing wouldn’t
be showing because of the color of this ink blot. T h e power of evil
is a recessive of thought. These things aren’t big a t first, and not great
in culture or artistic value but a r e all around us and a r e overpowering
good.
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“ T h e power of good is very simple and symmetrical and easily under-

stood. T h e power of evil is simple and symmetrical too, but you can’t
guess how simple it is. You can see how simple a n d evenly matched
i t is, W e should study it, and see what w e can do and try really h a r d
to overcome this power of evil. T h e power of evil might trick us because
of its apparent simplicity and it may not always follow the same course.
Simple tricks a r e put there to keep us from seeing through the real mean-
ing, But it can’t really be disguised and anyone can see. I t doesn’t
represent anything wanted and yet we sympathize with it. But we
really sympathize with the power of good for there is no reason for
the evil.”

( 2 ) . Inquiry.
1. “There are two mythical figures with their heads here and with
pointed hats and wings. You can teIl they are wearing shabby frocks
because they are uneven on the bottom and the edges look that way.”
2. “There are t w o vulture$ faci,ng toward each other with their heads
sticking u p and their wings down along the sides o f their bodies.”
3. “ T h e woman i s standing there in the center and you can see the
shape of her legs and bust. She doesn’t have a head.”

b. C A R D I I : Reaction T i m e 39”, Total T i m e 11‘38”.

(1). Main.
“This seems to represent two turkeys (Inq. 1) and they seem to be
angry a t each other. T h e y seem to be struggling with each other both
mentally and physically. I say that they a r e both equally a s mad a t
each other. ...
“Down at the bottom there is another figure that might represent a
turkey ( I n q . 2 ) . I t has thin legs and feathers, but f e w feathers are left.
It has just come out of a fight and has plenty of fighting spirit.
“When t w o people a r e angry at each other nothing will come of it
and there will always be anger left over. T h e same thing happens with
married people. T h e wife starts nagging because the husband can’t
make money and both think they a r e right. Other people may think they
a r e happy, but they a r e really angry and high strung and because they
a r e fighting between themselves they can’t agree with their friends and
a r e worn out both mentally and physically. T h e r e is nothing left f o r
them to do but make up.
 RALPH 0. VAN WATERS AND JEROME G. SACKS 75
“But when the husband becomes a success he will always remember
that his wife was not faithful when they didn’t have enough. T h e same
is true with the turkeys. T h e little turkeys will grow up to be scrawny
because they didn’t have a happy childhood.
“ T h e red (Inq. 3 ) stands for fighting and the black (Inq. 4) the
absence of fighting, the absence of happy qualities. ‘People want to
correct the fighting so that they may be happier themselves. Both parties
while fighting a r e praising themselves. While the wife points out the
bad qualities in the husband he will point out his good ones and when the
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husband points out the wife’s bad qualities she’ll point out her good ones.
Yet when they try to be peaceful the anger shows through and it always
shows that they have been fighting.”

( 2 ) . Inquiry.
1. “They have red heads and red ,necks with their beaks here. I
don’t see any legs. T h e bottom is d o w n here, and you can telt it’s a
bottom becuuse it’s heavy where all ihe intestines are.”
2. “This also reminded me of a small turkey with its head in the
center here. Its wings are scrawny and its legs are lighter than the
body and the top is a darker color to protect it f r o m the sun and animals
and rain.”
3 . “ I used the red for what these figures represent.”
4. (See main responre.)

c. CARD ZZZ: Reaction Time 25”, Total Time 10’.

( 1 ) . Main.
“This represents t w o people (Inq. 1 ) who a r e trying to forget the
troubles that surround them and tell jokes to each other and have a
merry time. T h e y seem to have succeeded fairly well.
“They have become adapted to the troublesome things around them.
. .
T h e y a r e doing the things you have to d o all day: eating, sleeping . ,
in a happier way, and they appreciate the things they have more.
“Some people want t o get more because that is the instinct-to become
great and rich-but they are really satisfied with what they have and
everybody is equal. T h e important things in life a r e health, happiness,
security, and to keep things like these, they have to be jovial and not
worry about the troublesome things about them. T h e y realize there is
a time for work and a time for play and a time to advance oneself.
T h e y look a t troubling things in a settled way and they a r e more secure.
..
“They a r e not rich. T h e i r clothes are not well cared-for. . They
a r e clean but they might be shabby. T h e i r jackets might not match their
pants, and the color might be different, but they keep their clothing up
and their thoughts clean.
“Impending dangers look bad (Ing. 2) but a s time goes on they can
be weakened with work. M a n is made to lead a peaceful and secure
life without the dangers of airplanes and dropping bombs. M a n is not
built for that but for health, security and family a n d although he might
 76 JOURNAL OF PSYCHOLOGY

be more intelligent than any other animal, man has to do different

things. H e needs his hands to write, for instance, o r to paint o r work
on the W.P.A. But he isn’t made for wars o r starvation.”

(2). I n q u i r y .
1. “TWOpeople a r e bending d o w n o v e r a washboard or something.
T h e clothes they a r e wearing look like wool.”
2. “ T h e red represents the p o w e r of impending dangers.”
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d. CARD l V : Reaction Time 23”, Total Time 9’.

(1). M a i n .
“This seems to me at first glance a picture of how the world w a s
started. A t first the sun is spinning around and a piece of the sun
flew out, which is hot g a s ( I n q . 1) because the sun is hot g a s and the
centrifugal force makes it g o spinning around. T h e sun w a s the mother
of this thing, so it spun around the sun and had n o reason to stop.
These hot gases turned to rock and .. . the rock t o water. Minerals
were finally formed making salt water. Putting these things together,
lightning came down from the mountains and oxygen was formed, and
because the earth w a s hot it formed steam and vapor and finally plants.
I see here a plant ( I n q . 2 ) . I t seems to come out from the black here
(Inq. 3 ) . At first it seems ugly but a green spot develops and it be-
comes beautiful.
“A plant develops ... no, I wouldn’t say that ... yes, well, a piece
is broken off and it lands in the earth and more plants grow.
“I see that from things that look base we can put these things together
and get something good out of it. If we put all the good characteristics
together we can see that a man has lots of good possibilities and is a
fine citizen and if we only point out the bad he m a y really become a
bad citizen and destroy himself and the things around him.”

(2). I n q u i r y .
1. “ T h e lighter parts d o w n here look like gas!’
2. “ T h e soft colored objects in the center look like leaves reaching
out into the sun. Th,ey a r e light green and dark green.”
3. “ T h e dark part d o w n here looks like soil!’

e. C A R D Y : Reaction Time 2’2“, Total Time 7‘58”.

(1). Main.
“This means to me that anything we do is only done after a period of
territory (sic) when first w e learn the alphabet ( I n p . l ) , then learn how
t o spell and then how to read.
“All of this preparatory work seems unpurposeful but there must be
some reason for it. T h e best we can do is to keep on doing it ...
until w e realize w h a t this work is for ( I n q . 2) and w e finally write o r
become a doctor or lawyer. Everything seems hard. W e must be taught
 RALPH 0. V A N WATERS A N D JEROME G. SACKS 77
difficult things and these seem unrelated. Finally in the last y e a r instead
of studying special subjects like chemistry, he is studying by learning
from patients who come to him and he finally graduates from medical
school. T h e y practice medicine until finally they have reached the peak
of their output and they grow old and at the end their output is low
a n d they die.”

( 2 ) . Inquiry.
1. “This is the beginning because there are roots here.”
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2. “And it widens out as it goes along. T h e color dafikens and w e

realize what our future will hold for US.”

f. CARD VZ: Reaction Time 2’50”, Total Time 10’.

(1). Main.
“This is a good example of a life of a man. First he is born ( I n q . 1)
a n d seems to be learning a n d wants to slycceed. He asks questions
about what happened before he w a s born, such as his grand-parents
and where he came from. He goes through school and this is a h a r d
period in his life ( I n q . 2). In college he works the hardest of all and
if he doesn’t succeed in college it will be a handicap.
“He becomes, let us say, a n engineer. He studies people around him
so that he will succeed. He keeps working h a r d and then he takes a
vacation ( I n q . 3 ) and then he finally decides that he will make more
money so t h a t he can retire.
“He goes back t o work. Finally after he works h a r d ( I n q . 4) he
retires and goes on a vacation and goes to the sea-shore with his wife
a n d family. He might be an artist, let us say, and d r a w pictures as a
hobby. He does this for a while but finally turns from his hobby when
he is older and his sons and daughters and grandchildren give him
parties to cheer him up and finally he goes on like that until he dies.”

(2). Inquiry.
1. “ T h e little knobs on the bottom down here are the start. They
represent the man and the woman!’ (S emphatically rejects the notion
that thfese knobs look like a man and a woman.) “It’s a pair of balls.”
2. “This represents when he is studying for a vocation.” (Lateral
lower D )
3. “This is the time before you decide to take it easy and before you
are getting old.” (Upper lateral d )
4. “Here you have realized your ambition!’ (Upper wing-like D )
5. “ T h e Iines in here represent something different. This is your
hobby!’

g. CARD YZZ: Reaction Time l’, Total Time 8’.

( 1 ) . Main.
“This represents a plan for success. First you start out (Inq. 1)
with what you want to do. You meet people and find out how the people
 78 JOURNAL OF PSYCHOLOGY

say to do it. First you gain experience and study h a r d and you try to
learn by studying before you gain experience. You keep working hard
a n d learn such things as geometry. You might rely more on experience
but you’re working so h a r d you decide to relax but it isn’t you t h a t wants
to relax but something else ... something else.
“People notice how lazy you a r e in comparison t o how you used to
be ( I n q . 2 ) , so you’re going to retrace your steps ( I , n g , 3) and work
harder to gain experience.” ( I n q . 1)
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( 2 ) . Inquiry.
1. “This black spot shows you are young and you w a n t t o g r o w up.
On this the who16 figure depends. I t doesn’t represent an object, just
a symbol!’ (Lower center d )
2. “Here you decide n o t t o relax so much!’ (Lateral d r extension
from middle D of the card)
3 . “Here you start working again.’’ (Inner upper extension d r of
upper D )
4. “Here you look back at life and decide that it isn’t all that you
can do, so you start working again.” (Upper d )

h. CARD YZZZ: Reaction Time 25”, T o t a l Time 8’20”.

( I ) . Main.
‘‘I see two animals that look like rodents. T h e y a r e f u r bearing ani-
mals, so-called, and they might be racoons o r skunks-about that size.
T h e y are flesh-eating animals and look for small birds and field mice
and smaller animals ( I n q . 1).
“This represents the father ( I n q . 2 ) .
“This represents the mother ( I n q . 3).
“And the animals go out into the forest ( I n q . 4 ) and they t r y to be-
come friendly with other animals but they learn from experience it’s
better to stay alone and they become more vicious and destroy poultry
(Ing. 5 ) .
“After they have matured they start eating less,-this is the mating
.season. These d a r k lines represent they a r e fully matured and they need
a mate ( I n q . 6). But they can’t find each other and so they go back
from the forest and find a large group of racoons.
“I see that in later life they seem to represent their father but it’s
really their mother that they really come from ( I n g . 7 ) .
“They show scars because they have come in contact with larger ani-
mals and they have been fighting. And this shows that even though you
think you are good there is always somebody better than you are.
“They seem like beavers: , .. but if they are racoons they prefer
low trees to high trees because they have heavy bodies and a r e not agile
and a r e not able t o climb much (TeJting the Limits).”
 R A L P H 0. V A N WATERS A N D JEROME G . SACKS 79

( 2 ) . Inquiry.
1. “ T h e y look furry. I scc their heads w i t h thrir ryrs and thrir ears.‘’
2. “ T h e fathcr is strongrr so it’s red.” ( L o w r r r c d )
3. “ T h r mothcr is wcakrr so it’s orange.” ( L o w r r orange)
4. “ T k c forest is dark blue and the red of thc animals is so different
from this color that thrre is a battle between t h r m so the animals fight
the battle of survival.”
5 . “ T h i s is a mixture of the forest and it shows the animals’ atti-
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tudes.” ( U p p e r D )
6. “ T h i s linc shows that thcy arc maturrd and start eating less and
nerd a mate.” ( U p p e r center line-di)
7. “ T h e y seem to rrprcsent their f a t h r r because the color is the same,
but this line comes up from the mother!’ ( L o w e r d i center line)
Tcsting the Limits:
( T h r subject is concrrncd about the squatty, irrr-like upper D. H e
had previously rejected this as a single tree [Sec Inquiry 51, and had
usrd it for color symbolism. But the shape ties in w i t h t h e animals’
prcfercnce f o r low trees. Hc,nce, the hesitation and strcss on t h e animals’
lack o f agility.)

i. CARD I X : Reaction T i m e 31”, T o t a l T i m e 9’.

( 1 ) . ill&.
“This seems to represent a volcano. On the bottom is the red coloring
which represents the hot lava inside ( I n q . 1 ) . O n the top the red and
green is the whole mountain. T h e green represents the vegetation
( I n q . 2). In the center I see a n orange and green geyser (Inq. 3 ) which
represents from what this volcano is derived from ... : as I said
before, ( S refers to C a r d I V ) , hot gases and bacteria.
“ T h e hot lava is covering over the plants so that finally there w a s
plants and vegetation mixed together a n d it seems t o me that all the
vegetation went back into a form of stone again. Maybe some bacteria
w a s left but it is really all decreased. .. .
“ W e have no foundation for saying that a m a n goes to Heaven when
he dies. W e say this’because he was so good that we must believe that
this must be so. In the same w a y if he is bad w e want to think that he
goes where he is punished. But we really have no basis for saying this.
“On the top the red and orange represents the flames and hot gases
( I n q . 4) given o f f by the lava which rises into the sky. T h i s represents
one person doing good things. T h e r e will always be a memory of the
good things done or of the bad things.”

(2). Inquiry.
1. “ T h i s rcprcsents rrd-hot lava.” ( L o w e r pink D )
2. “ T h i s looks like oegrtation because of thr color.” ( C r e r n D )
3. “ T h i s looks like a geyser with the hot gascs and spray coming u p
from it.” ( U p p e r centrr D )
 80 J O U R N A L OF PSYCHOLOGY

4. “You can tell this f r o m the color and it’s h o i and smoky.” (Upper
orange D )

j. CARD x’: Reaction Time 1’45”, Total Time 8’.

(1). Main.
VA “ T h i s is an Eastern Mohammedan ... , an Eastern theory of
how the world is built. I t seems to be a hollow shell (Inq. 1) and in-
side is an elephant (Inq. 2 and 3 ) keeping the world from collapsing
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(Inq. 4 ) and ... , I t seems to be more of a religious theory than a

physical theory. I t seems that the world will breed only evil and it must
be destroyed. I t might appear to be good a t first, but it will turn out
evil. After the world is destroyed by the Maker, who is supposed to
control all things, the world will cave in a n d all the people will fall
into the center and be punished for all the things they have done.
“I can see the power of God and the power of the Devil here (Inq. 5 ) .
God wants the people to g o to Heaven and instead of caving it will
expand. ( I n q . 6, 7, 8 ) .
“But even if the people t r y to be good they will think that power itself
is really more important than doing good. I can see that all the people
won’t die out at one time, but gradually. I t will happen in one section
of the world and then another until finally all the people of the world
will be extinct. T h i s shows that it is better to be helpful than to punish
one that has hurt you. And that’s the way children should be brought
up.”

( 2 ) . Inquiry.
1. “ T h i s is the hollow shell.” ( R e d D )
2. “These innrr blue figures are elrphants holding thr world apart.”
3. “ T h e green might remind me of elephants because elephants live in
junglrs.”
4. “ T h e brown figures down hrre hold ihe shell f r o m coming to-
g eth e r.”
5 . “ T h e brown red is ihe powccPr of tlic Drvil.”
6. “ T h r s e Jigures on the outsidc rrprrsrnt figures holding the c o r l d
from expanding. T h e y could be spiders or crabs.”
7. “ T h e brown figures d o w n here are holding the earth from r x -
ploding.”
8. “ T h e grern is associated with the idea of spiders because spiders
live in grass.”
Testing the Limits:
( T h r subject perceived ihe popular crabs “because therr are so many
claws and legs” but could not accepi this concept since the green figure
forms the association with spiders-“Thry liwe in grass.”)
 R A L P H 0. \‘Ah’ WATERS A S D JEROME G . SACKS 81

2. Quantitative Findings and Ezlnluatiotr

T h e quantitative findings are given in T a b l e 1. From the nature of the
responses it can be seen that any scoring scheme which might be used would
be arbitrary. Wherever possible the scoring method described by Klopfer and
Kelly ( 6 ) has been used. Because the subject was engaging in free associa-
tion throughout, it was necessary for the examiner to feel his way during
the inquiry. T h e r e were times when the narrative was obviously related to
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the formal aspects of the Rorschach plates. A t other instances the blots
themselves appeared to have little connection with the associations. Conse-
quently any conclusions based upon the quantitative material alone must be
made with caution.
TABLE 1
RESPONSES:
42
~ ~~

w 50% H 3
D 3370 A 8
d r 17% Sex 1
K 1 i\ +. i i , Abs. 19
F 14
Fc 0 (4-1)
F + : 217’0 c 3 (4-1) -
A : 19% C’ 1 42
P: 3 C F 2 (4-2) Total Time 92’
0 : 22 (20 minus) c 10 Time per response 1’10’’
Succession: loose - Achromatic R / T 80”
Approach: - W,dr 42 Chromatic R / T 45”

O n e is first impressed with the freedom and looseness of Edward’s associa-

tions. H i s disregard for form, his feeling of distance from the card and his
tendency to perseverate the central themes are indications of some disorgani-
zation and poor control. But we also have some indications of a former if
not actual high capacity for constructive thinking. T h e r e is, for instance,
the high form level together with a careful if not overmeticulous regard for
meaningful detail in some responses.
Edward quickly bends everything to his own interests, and his associations
become autistic and highly symbolic. Frequently, the formal character of the
blot suggests, through devious associations and logic, the struggle of man
with the forces around him. Edward’s behavior during these recitals deserves
comment. H e approaches his task with deliberation, confidence, and detach-
ment. His eyes shift from the card itself and he peers with apparent con-
centration into space while continuing his narrative and free association. H i s
disdain for things going on around him, his disregard for the concrete and
his flights into fantasy suggest a disturbance in constructive thinking and an
 82 J O U R N A L OF PSYCHOLOGY

inability to deal with abstractions except in a n autistic framework. T h e r e

is no loss in the ability to abstract as such, nor is there evidence of “inability
to deal with that which is not real.” B u t there is difficulty in handling
concrete material and his disturbance in dealing with this is on a n associational
level. T h i s may be considered to be a special case of the “process of dis-
integration toward the concrete” described hy Goldstein and Scheerer ( 3 ) .
Edward shows evidence of confusion in dealing with environment. From
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what we may surmise from the quantitative material there is inattention

to pertinent detail, loose and variable control particularly in his color asso-
ciations, relatively few popular responses ( P = 3 ) , o r figures which are con-
ventionally seen (A%=19). H i s reaction times are long but there is little
evidence of “shock.” D u r i n g these periods of delay the subject is apparently
constructing elaborate abstractions, since once his expositions begin they
assume the fullness and roundness of complete and whole associations. H e
spent over t w o minutes, for instance, before responding t o C a r d V, and o n
this card he avoided the most popular association on the Rorschach and
constructed instead an abstract D W association, suspiciously confabulatory
and based upon the leg-like projections which he regarded as roots. We may
note, too, in the response itself an interesting expression :
This means to me that anything we do is done only after a period
of territory when first we learn the alphabet, and then learn how to
spell and then learn how to read.

T h i s distortion in the use of words is more than accidental. Edward ex-

presses confusion in differentiating t h e concepts of time and space. These
are blended and substituted with equal value throughout. W e may note,
too, his use interchangeably of the pronouns “we” and “he.” O n C a r d V
and elsewhere the subject apparently regards E d w a r d as a separate entity
from himself and frequently discusses him in the third person. From this
evidence we must recognize that the subject experiences real confusion in
dealing with his environment.
Despite the recurrent ambition theme, especially noticeable on C a r d VII,
imagination is poorly integrated in his attempts to relate events to himself.
T h e subject is strangely distant, appearing as a spectator of his own life
drama, observing what others think of him and watching his o w n responses
and adjustment to them.
People notice how lazy you are in comparison to how you used to be,
so you are going to retrace your steps and work harder to gain
experience.
 R A L P H 0. VAN WATERS AND J E R O M E G. SACKS 83
T h i s implies social awareness and sensitivity to the evaluation of others.
But the subject’s feeling of distance implies a divorce of responsibility from
final effects. Hence, although his drives seem to be directed toward achieve-
ment and success, the imagination itself lacks purpose since there is no per-
sonal responsibility for the act itself. Inevitable forces around him control
the end result and are, in fact, the very source of the achievement drive itself.
O n objective standards, Edward shows variable precision in his responses
and yet there is no recognition of this on the subject’s part. H e expresses
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satisfaction and confidence in regard to his performance. Some investigators

( 6 ) have noted that the subject with intracranial damage may give low level
responses, repeat them again and again, be aware that these responses are
inadequate, but be unable to alter the performance. T h i s “organic sign” is
not present in our subject. Whereas Edward may initially respond to some
formal aspect of the card, he is easily carried along by his own interests and
preoccupations so that in the end precision becomes largely a subjective
affair. T h i s is not, however, a characteristic “organic sign.” Actually, the
subject expresses a distrust of the world as it appears. People and things are
not really what they seem. W e may consider this a delusional state but a
differentiation between a “normal” and “abnormal” ideational point of refer-
ence may not be precise.
O n e cannot fail to be impressed by the aggressive responses and the
destructiveness and violence of his associations. Uncontrolled color responses
are common in this record and though they are accompanied by violent acts
are completely divorced from the subject’s feeling of responsibility and
control. I n Card X, for instance, he sees the world destroyed. Here again
his r6le is that of a spectator who observes destruction but because he is not
a part of it his interest is largely that of a historian.
T h e subject shows considerable shading preoccupation of the undifferen-
tiated sort ( K , c, C’). T h e r e is a high frequency of small rn responses. T h i s
is evidence of residual tension and conflict but the depressive elements are
no longer insistent. Edward’s utter unconcern with consequences, however
morbid and destructive, is an indication that depression is no longer an
important aspect of this personality. T h e number of abstract ideas with
personal reference presents the possibility that it would not require deep
probing to elicit delusional material from this subject. H e expresses, for
instance, preoccupation with origins and paternity. T h u s on Card V I :
H e asks questions about what happened before he w a s born, such
as his grandparents and where he came from,

His concern becomes insistent on Card VIII where the animal figures are
 84 J O U R N A L OF PSYCHOLOGY

seen as resembling their father, “but really it’s their mother that they really
come from.”
I n summary, the autistic thinking, the abstract responses with personal
reference, the variation of form level in one card, the contamination, and
the general extratensive trend are consistent with patterns displayed by sub-
jects in a schizophrenic state. His W responses are high, poor in form, and
have characteristic vagueness and abstractness. T h e r e are relatively few
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popular responses in this record and the A% is low. Any evidence of organic
brain damage as far as Rorschach findings are concerned is purely secondary,
and in any event might be consistent with a schizophrenic pattern. H e does
not express impotence and perplexity, nor are his responses sticky in per-
severation. H e does not restrict his responses to a level of pure form. If
any organic signs are present they are of a special type which may be charac-
teristic of prefrontal lobotomy cases. T h e principal signs in this record are
the subject’s lack of responsibility for consequences and the divorce of
imagination and affect. W e may conclude that the schizophrenic state exists
in this subject at this time. W e are unable to state whether this condition
will result in further deterioration. A n interesting but highly speculative
possibility exists: that the old depression and anxiety in this personality gave
it control, but that its absence now permits the free expression of schizo-
phrenic trends which have been noted in the record. W e are not prepared
to state, however, that the disabling effects of his psychosis state will prevent
satisfactory extramural adjustment in the future.

C. OBSERVATIONS OF THE PSYCHIATRIST

T h e patient was first seen when he was 15 years of age. At that time, his
family became alarmed because two weeks previously he had declared that
he had been hypnotized. H e had written a letter to this effect. H e stated
that a girl friend’s father had hypnotized him and that this man was
“probably a psychiatrist.” T h i s acute delusional state lasted only a day or
two and at the time of his examination, he was quite evasive about this
episode although he was superficially friendly. H e would not admit that he
felt hypnotized. H e talked chiefly about his desire to be a doctor. H e said
he had no urge to make social contacts of any sort. H e was not upset about
this and claimed that he was quite content to remain this way the rest of
his life. H e was unable to see that there was any discrepancy between his
desire to be a doctor and his lack of social drive. H e was somewhat grandiose
about his intellectual abilities. H e gave the impression of being bright, but
there seemed to be no remarkable talent or ability,
 RALPH 0. VAN WATERS A N D JEROME C. SACKS 85

His family stated that he had always been a problem. From his earliest
years he had been a feeding problem. W h a t had disturbed them more than
anything else was his difficulty in socializing. H e showed very little inclination
to play. H e had few acquaintances and no intimate friends. He tended to
stay in the house and his family literally had to force him outside to play.
H e had given as an excuse the fact that he was clumsy and that he had
always avoided active athletic games. His school work was average until
the ninth grade at which time he got A in all subjects as well as A in conduct
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and effort. His intelligence quotient from an unknown test given at school
was recorded as 120 at that time. In high school, he received A’s and B’s
and his teachers felt that he was reliable and cooperative. T h e next year,
which was the year he became sick, his work slipped considerably, but still
he was able to receive grades of B and C in his subjects. T h e boy stated
that he had had no sexual experience other than masturbation. H e had been
masturbating for two years on a compulsive basis without any sexual imagery
and chiefly to relieve tension, as he put it.
Shortly thereafter, his schizophrenic pattern blossomed forth in full force.
This occurred while he was at another city and he was treated with electric
shock. T h e psychiatrist who saw him stated that he was suffering from
dementia praecox of hebephrenic type. H e gave him 20 shock treatments.
There was only very transient improvement. H e returned to Boston and
was seen again in a hospital, six months after his first visit. H e was con-
fused, vague, apprehensive. H e had auditory hallucinations. H e said, “Voices
confuse me-they call me a dirty Jew.” T h e voices were “musical” and they
would call out his name. H e felt that his body had changed and that his head
was flat on top. H e also held to the belief that some doctor had tried t o
experiment with him. H e was aware of the fact that something was wrong
with him and that his trouble was with his thought processes. H e believed
that something was preventing and interfering with his thoughts from becom-
ing clear. H e made the remark that he often heard voices but that he thought
it might be his conscience. A good deal of the time he was incoherent,
irrelevant; his mood was inappropriate and flattened. H e remained in the
hospital for over two months and received insulin therapy, coma occurring
40 times. He seemed temporarily improved, but several days after leaving
the hospital, his schizophrenic reaction recurred in full force.
A bilateral prefrontal lobotomy was performed on the twelfth of June,
1946, about three weeks after leaving the hospital. Immediately following
the lobotomy, he behaved in a confused fashion, was very stubborn, grunted
apparently to imitate animals, tore wallpaper from the walls and was quite
 86 JOURNAL OF PSYCHOLOGY

destructive. Within several weeks, however, his disturbed behavior subsided

and he appeared to be much more cheerful. H e played the radio a great
deal and was able to work in the occupational therapy shop. H e was dis-
charged from the hospital about a month following the operation. H e was
much more sociable and talked freely. T h e r e was no evidence of hallucina-
tions a t the time of his discharge. Since then, he has been seen on several
occasions. H e went back to school in the fall term and has received average
marks since. H e was more friendly and his family states that he has shown
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greater ease in the presence of other people. H e recalls his past delusions and
hallucinations. H e does not like to talk about them, but states that they
were entirely nonsensical. As far as the family is concerned, there has been
no return .of psychotic trends. His memory is intact and he seems able to
grasp rather complicated concepts. H e is somewhat more independent than
previously, but there is no belligerent or impulsive behavior. T h e r e still
have been no warm attachments made and he does not give the impression
of being capable of forming deep emotional ties.

D. CONCLUSIONS
I n this case of bilateral prefrontal lobotomy we must note the absence of
Rorschach “organic signs” of intracranial pathology. Hanfmann and Kasanin
(4) observed a coijperative attitude but ineffectual performance in brain
damage cases and contrasted this to the resistant attitude of schizophrenic
subjects. Klopfer and Kelly (6) mention the sticky and rigid perseveration
of the “organic” with emotional lability and flattened affect. Piotrowski’s
“organic signs” ( 7 , 8, 9) are well known to all clinicians familiar with the
Rorschach and will not be enumerated here. But what is most striking in
this case is the absence of indications of intracranial organic damage on the
Rorschach test if we limit our observation to a hunt for signs.
Stanley Cobb ( 1 ) has cited the findings of Freeman, W a t t s , and Lyerly
on 125 “prefrontal lobotomies.” T h e primary effects resulting from the
operation were lack of ambition, indifference to the opinions of others, inertia,
reduction in consecutive thinking, and self-satisfaction with a performance
which might be poor in quality. Secondary results were euphoria, talkative-
ness, evasion, moria, inattention, poor judgment, and aggressive behavior.
These investigators have pointed to the loss of imagination in these cases
but have stressed the divorce between imagination and affect. Because the
individual is unable to project himself into the future, his disappointments
and regrets for the past, and his ambitions and fears for the future are
particularly affected.
 RALPH 0. VAN WATERS AND JEROME G. SACKS 87

W e have discussed above the divorce of imagination from affect in our

subject. Indifference and lack of affect is apparently related to the subject’s
feeling of fateful forces which are operating outside his control. Yet on a
verbal level at least, it is hardly true that Edward shows lack of ambition
o r indifference to the opinion of others. Reduction in consecutive thinking is
true in our subject in only a limited sense and perhaps in the sense which
Goldstein (2) uses when he notes the difficulty of patients in organizing and
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relating concrete material.

Kisker ( 5 ) , in analyzing Rorschach records of lobotomy patients, con-
cludes: “An analysis of postoperative scoring signs reveals the presence of
several of Piotrowski’s criteria of intracranial damage, but since they fre-
quently appeared in the preoperative picture it was felt that they were more
a function of the psychotic process than of the lobotomy. I n general, it
appears that the neurosurgical intersection of the frontal associative areas
plays a less important r6le in the reorganization pattern than does the pre-
psychotic and preoperative personality structure.”
It is not uncommon that the lobotomy operation is performed when the
question of schizophrenia is paramount. If, as Kisker suggests, the psychotic
picture is more dominant than the possible lobotomy or “organic” Rorschach
signs, then the postoperative condition of the lobotomy patient may be
assessed on the basis of qualitative and quantitative findings of the Rorschach,
but the pattern of schizophrenia can be understood only in relation to the
preoperative picture on the one hand, and the postoperative extramural
adjustment on the other. It is by comparing the preoperative and post-
operative pictures that the Rorschach test may have value in predicting
subsequent adjustment.

E. SUMMARY
W e have described the Rorschach record of a 17-year-old boy who was
given a Rorschach test nine months after bilateral prefrontal lobotomy. It
was determined in the test evaluation that the subject shows indications of
a schizophrenic state. Psychiatric examination which was not available at
the time of evaluation indicated that the patient had been diagnosed as having
“dementia praecox, hebephrenic type” prior to the operation. So-called
I1
organic signs” are absent or secondary in this record. There are indications
of divorce of imagination from affect. It is emphasized that it is difficult
to assess the disabling effects of the schizophrenic state from the Rorschach
examination alone. I n order to predict a future trend, assessment should
be made of the preoperative schizophrenic state in relation to present findings.
 88 JOURNAL OF PSYCHOLOGY

REFERENCES
1. COBS,S. Borderlands of Psychiatry. Cambridge: H a r v a r d Univ. Press, 1943.
2. GOLDSTEIN, K. T h e Organism. Yonkers-On-Hudson: American Book, 1939.
3. GOLDSTEIN, K., & SCHEERER, M. Abstract a n d concrete behavior-An experi-
mental study with special tests. Psycho/. Monog., 1941, 53, No. 2.
4 HANFMANN, E., & KASANIN, J. A method for the study of concept formation.
J . of PJychol., 1937, 9, 521-540.
5. KISKER, G. W. T h e Rorschach analysis of psychotics subjected t o neurosurgical
interruption of the thalamo-cortical projections. Psychiat. Quarf., 1944, 18,
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43-52.
6. KLOPFER, B., & KELLY,D. T h e Rorschach Technique. Yonkers-On-Hudson:
World Book, 1942.
7. PIOTROWSKI, 2. A. On the Rorschach method and its application in organic
disturbances of the central nervous system. Rorschach Res. Exch., 1936-7,
No. 1.
8. -. Positive and negative Rorschach organic reactions. Rorschach Res.
Exch., 1940, No. 4.
9. -. T h e Rorschach ink-blot method in organic disturbances of the central
nervous system. J. Nerv. U Ment. Dis., 1937, 86, 525-537.
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