a lover's humility. The real ego is regarded as poor and miserable, to be sure, but the love has not gone out to another ego or rather to another person's ego, but to his own, or a part of his own, to a tyrannical fantastic super-ego which knows nothing of clemency or proportion. At one moment he basks in an illiterate barber's flattery and sees in it a recognition of his due; at another he is no less a person than the World's Greatest Outcast1. The narcissistic nature of the Super-Ego has already been referred to in an earlier paragraph and will be mentioned again. It is the absorption of the libido in this part of the ego system which makes melancholics so difficult to handle in any form of psycho-therapy, particularly since the super-ego is mostly unconscious.

(d) Melancholia and Mania. Melancholia and Mania are associated in respect to the following points among others: (i) the same people may have both affections at different times in their lives, sometimes alternately, sometimes switching over' from one to the other with apparent suddenness2, (i) in both the ego plays an outstanding part in the patient's libidinal distribution and often in his manifest symptoms, though in the one case he feels ill and weak, wicked and an outcast, while in the other he feels bursting with spirits, ready for anything, a good sort of fellow and the friend of all men; (iii) in both there is an incapacity to work and to love, in melancholia work is too hard, in mania 'too easy,' in both love is a shallow thing, the former seeks it but can nowhere find it, the latter cannot stop to experience it.

To the psycho-analyst one of the most remarkable features of the change from melancholia to mania is the alteration in the functional activity of the super-ego, in the former state it makes a persistent relentless attack on the ego, in the latter state it seems to have disappeared altogether. This is a descriptive way of stating the matter that needs correction. It would be better to say that in melancholia the cathexis is transferred to the super-ego and is withdrawn from the ego, which is weakened, while the super-ego exercises its sadistic vigilance over the ego; in mania the ego is released from its former rigid control, receives the entire amount of cathexis formerly investing the super-ego and proceeds with feverish activity to long prohibited infantile gratifications. This at least is one of the possible results of the transfer of cathexis, another is megalomania of quiet type, exaltation of spirit (euphoria) without the manifestation of interest in the outer world,

1 The incident also shows the infantile nature of libido gratification. He stroked his hair and then he sniffed his hands, this recalled a part of his lavatory ceremonial; the use of French was a part of his play with words which entered into his earliest phantasies; the fierce heat of his outburst at the amount of the bill (which was not excessive for what he had had done) revealed the sadism which later appeared in his self-accusations; the whole incident was also a revenge and a compensation for a recent petty financial extravagance of his wife. Only an individual with an infantile fixation could have behaved in this way. The ego was behaving in infantile fashion to find compensation, for an academic setback in the mumblings of a barber, and for a domestic dispute in a hair-cut. His emphasis on the persistence of the fragrance of the barber's oil may throw some light on the manner in which the ego finds its compensations for a material loss in an aesthetic sensual gain. Since he was a person with considerable natural endowments and knowledge of the world before his illness, it is hard to see how, without taking into account the infantile libidinal element in his mind, he could have been so powerfully affected by an incident in a hairdresser's saloon in the Euston Road.

2 The suddenness is more apparent to casual observation than to analytic investigation. The incident at the barber's showed evidences of transition, and in another case where I could trace no regular periodicity in the cycle of events I was usually able to tell from the transference three days beforehand when the manic phase was beginning, though the patient only knew a few hours beforehand that something was impending.

which type results being determined presumably by the amount of objectcathexis existing at the time. The manic phase does not eliminate the hypochondria, and indeed on theoretical grounds one would not expect this to happen, but its expression is masked by the lack of subtlety in manner and phrase which frequently accompanies the disease.

The melancholic phase is characterized by mental pain of the acutest kind, which is borne by the ego; when the manic phase comes there is sudden release of strain and the patient appears to be joyous. The change may be put in terms of the difference in tension or hostility between the super-ego and ego. Probably the capacity of the ego to tolerate the super-ego is widely different in the two states. That the condition of the ego seems to be important is shown by a further fact, that mania is much more infantile in character, or rather that the manic's ego activities, as well as his libidinal, are more infantile. To give an illustration: in the depressed phase a patient had prospect of a rise in the business world but feared that he was emotionally incapable of doing the extra work involved; he saw his career clearly, the present, past and future, and was aware of intellectual proficiency. Later in the manic phase he decided to cling to his present job, dwelt on its trivial pleasantnesses and behaved childishly about the past in retrospect. As to the future: “I don't give a damn what happens. I'll stick where I am till Hell freezes." Comprehension of surroundings is of course in melancholia impaired in most cases to a greater or less degree, and overcast with uncertainty and portents of evil, but it retains its character of comprehending (bringing elements together) though the total range is restricted. In mania this is not so, here details, isolated elements or small combinations seem to function in the mind where larger combinations function in depression. [I have not found this point mentioned in the literature and intend to refer to it in more detail in another paper.] It may be that the difference lies in the ego alone or in some non-ego change in the ego-super-ego relationship; at present it cannot be decided. Attention may therefore be directed to another aspect of the problem.

There is strong clinical evidence that in depression a person is being attacked; this person, whom the patient formerly loved, has been introjected (absorbed into the ego system) and in this new psychical position is the object of hostility. In hitting the object the patient hurts himself. The ambivalence to the object is transferred too; the adoration and the loathing. But what happens in the manic phase to the introjected object? Psycho-analysis is not yet ready for an answer to this, but it seems that sometimes the object cathexis is given up and the patient is in a measure objectless.

Perhaps the most striking characteristic difference is the immense sense of guilt in the depressed phase and the guilt-free state in the manic. Sin in the one case, surpassing the mercy of God to forgive, and utter indifference to moral values in the other. What is this sin?

(e) The role of oral libido in the melancholic. A patient came to me for consultation in a state of frightful agitation, on all sides his attention was directed to objects and situations which brought to his mind thoughts of Blood. When he got on a bus the idea came to him, "Suppose my children were in the roadway and got run over..." then he saw in his mind's eye gouts of blood on the bus wheels, rivers of blood in the road and mangled flesh. "And worse thoughts than these...I can't eat...without thinking..." he stopped. I added, "Of human flesh." "Yes, that's it, when I sit down to eat I keep on thinking that it's human flesh...my children's." His family doctor

(diagnosing this as neurasthenia) had ordered him for the sake of fresh air and exercise to dig in the garden. "But," he said to me, "when I do I think as I turn over the sods with my spade, 'It's all flesh. The entire earth must be by now made up of rotting corpses.' And while I work I feel 'It's everywhere, everywhere. Even the vegetables which grow in the soil are made of human flesh.""

This case has been given because it represents in a peculiarly condensed and forcible way the importance of the oral fixation in melancholia. Abraham drew attention to this first; what follows is based on his papers. The oral stage is sub-divided into a passive sucking stage and an active biting stage, the former is objectless, the latter is characterized by a peculiar relation to the object (the nipple) which is no longer regarded as a part of the self but is assuming (psychically speaking, of course) an external position and is felt to be in danger of being lost, a matter of importance because it is a source of pleasure. The nipple is seized on and devoured, it is drawn into the Selfsystem (the pleasure Me-system) to be retained. This happens at the time of weaning when the child's jaws are beginning to function (aided by teeth) in masticating food, no longer merely rhythmically pumping it into the upper end of the gut. The bite movements are not reflex peristaltic pulsations but voluntary efforts; the real ego, consciously controlling and modifying action to meet and master the outer world, is beginning to function in the bodily and psychic economy. Heretofore the world has come to the mouth, now the mouth goes to the world. This phase is accompanied by a psychical tension and excitement which finds relief in the act of gnawing and destruction. It is not to be supposed that the destructiveness is consciously felt as it is in the case of youths who revel in it on Guy Fawkes' Day and other celebrations, it is not a pleasure in seeing a complete and meaningful structure toppling to pieces or consumed in flames, it is rather the fierce pleasure in detaching pieces that attract and then mastering them with the means at the ego's control: : jaws and claws.

This, the stage of oral sadism, gives place to the 'negative' anal stage, in which the attitude to the object (now faeces) is still aggressive but the desire is to expel the object with the intention of alienating it from the psychical system. But the impulse does not run its course unchecked, for in the earlier phase the tendency to passivity persists. The child cannot change its habit in a moment, old behaviour disturbs the acquirement of a new. The pleasure to be gained at first is not solely the thrill of passing but the steady sensation of pleasure when retaining; the muscular strain in and pleasure from the sphincter is balanced against the other pleasure to experience the sensory pleasure in the passing. The stool is after all a part of the self. Thus there is ambivalence at the anal stage as at the oral. This ambivalence is evidence of an unstable ego-object relationship which we must now consider more deeply. In the preceding paragraphs we have considered two phases of oral activity, one passive, objectless, and the other with an active destructive orientation to the object. This object was originally the nipple, which was the main thing in the suckling's world. The fixation at this stage of libido development means that there is a tendency to hark back to the infantile desire to suck and bite the nipple of the mother (the spontaneous utterances of melancholic patients show this tendency clearly enough in analysis) and that the behaviour of the patient throughout life is dominated in varying degree by those mental characteristics which belong to that phase: a sadistic attitude combined with

an overstrong tendency to introjection; the object may be changed beyond recognition, the tendency is not.

The child cannot permanently satisfy its libido at the pre-genital zones. It appears as if the libido must undergo a shifting of its concentration from one zone to another, oral, anal, genital, each being accompanied by a change in the ego, partly independent, partly dependent on the libido alterations. A little later the love-objects are no longer the self or parts of the self but those most important things in the environment-the parents. These are adored and feared, they have it in their power to give almost unconditioned happiness or to impose restrictions on pleasure to an unlimited degree. While they are loved the child is physically, mentally and morally wholly dependent on them; when they are hated, the child stands perilously alone. Obedience is rewarded by marks of their pleasure, of their love, disobedience by their displeasure, and their love is withdrawn. When this happens, the child is indeed helpless. Furthermore the parents require such extraordinary things, among others that the child shall acquire voluntary control over its "autonomic" nervous system-at least in places-that it shall defaecate at 9 a.m. and not urinate while it sleeps, that at all times it shall be celibate in thought and deed and indulge in no 'smoking-room stories,' ordinances which at least half the adult population would regard as ridiculous if applied to themselves (unless they had already inured themselves to obedience to them) are to be observed at the cost of parental displeasure-loss of love. It is not to be wondered at that there is a conflict in the child's mind between an inner longing for that love and an inner hatred of the people who act against its immediate self-interest (personal pleasure as it has hitherto experienced it). There are several possible outcomes, chief among which are the following: (i) the child's self-love may be gratified by a peculiar procedure-it identifies itself with its parents, takes their 'you must' (external) as 'I must' (internal) and so solves the external conflict by making it internal. The external injunction becomes now an internal one, and self-satisfaction (self-love) can be preserved so long as the orders are obeyed. The hostility to the interfering parent is transferred to the introjected parent (the Super-Ego) and is turned upon the self; this is where the Super-Ego gets its relentlessness, it is sadism reflected and made less dangerous, at least to outer objects, to whom love feelings can now flow out, undisturbed by hate1. (ii) (a way leading to abnormality). The severity of the Super-Ego may be restricted to certain specific performances and not to all of those that the parent has prohibited, the introjection of prohibitions can be isolated from one another so that the individual has a conscience (super-ego function) that operates towards one type of instinctual gratification differently from that of another without developing unification of the 'moral character.'

From these two modes of Super-Ego formation result two different types of Super-Ego; in the one there is integration of the prohibiting tendencies, in the other there is not. The latter is for our present purpose specially important because it is correlated with unintegrated libidinal gratifications, i.e. those which have given rise to fixation and have (by repression) acquired to a certain extent an independent existence in the psychical economy. In the case of the future melancholic the process appears to be as follows: the

1 Thus the impulse of sadism retains its sexuality when directed upon the self in melancholics, but is aim-inhibited when it is turned upon outer objects-another evidence of the auto-erotic feature of the disease.

individual being greatly desirous must check the strong libidinal tendency to get erotic gratification by sucking the loved object and devouring it. This is not a simple forward movement of love, he also hates it and wants sadistically to destroy it, but the sadism is turned against the self via the Super-Ego, so he punishes himself for the cruel lust by making painful the very source of his pleasure. His appetite is altered because he feels himself to be a cannibalbrute to the very objects he loves. He is right, of course, he has these desires, his Super-Ego with its usual precision blames him for his deepest ('most repressed') wish, and hauls it up before his eyes, as it were, as a perverted taint in his character. The ego of the patient, not comprehending the presence or the source of the desire, says, "It's horrifying to me to have such thoughts, they are no part of me," reckoning as Me only what is conscious. The SuperEgo, however, knows more of the instinctual desires than does the ego and sits in harsh judgment.

(f) Efforts at Self-Cure. It is necessary to know what has caused neurotic illness before we can estimate how far our efforts or the patient's are likely to alter his condition in the right direction. Among the causes of neurotic illness1 frustration holds the most prominent place. This is an external factor and occurs when, after deprivation of an object of gratification, there is no substitute. The effect of frustration is to dam up the libido so that it creates a state of uneasiness; this is relieved either by a transposition into energy directed to the outer world which is made finally to give the actual satisfaction required, or else the libidinal satisfaction is deflected from its erotic goal and sublimated. The danger in either case is that the person will turn from reality and use the psychical energy whose external outlet is blocked in re-animating old phantasies and regressive aims.

Two other causes are the inability to adapt to reality, which may precipitate neurosis at any age, and inhibition in development, for the action of which a certain stage of development is required. In more pronounced cases, the latter of these two causes is due to the former.

The fourth type of nosogenesis deals with the capacity to tolerate only certain amounts of libido, if these are exceeded the patient falls ill because his ego cannot cope with the task of repression.

With this outline in mind, let us approach the question, what makes the melancholic fall ill? In some cases the attack begins after a real loss, in others no such external cause can be found, and presumably an illness of an organic nature predisposes to the melancholia only because it weakens the ego's capacity to tolerate a certain amount of libidinal tension.

Let us turn to the events of childhood, in particular the peculiar melancholic Oedipus situation. Like all children, these patients in this stage of development desire as an expression of the love of their parents to have a child from or by them. All children are of course frustrated in this, but the melancholics-to-be treat this as a narcissistic blow, as a castration, and being weak in their genital organization regress to earlier levels. If they had more capacity for object-relationship they would be able to divert their libido to other objects, but theirs is a narcissistic character and they cannot do this. What object-capacity they do possess also takes a regressive turn and they strive to keep the object by the means which their fixation ordains, viz. by oral

1 Freud, "Types of Neurotic Nosogenesis," C.P. 1, pp. 113-121.

This is to be distinguished from a stationary infantilism by the fact that there appears to be an effort to overcome the infantile fixations.

Med. Psych. VII

8