Certain other signs which have been believed to support a diagnosis of masturbation, do not even justify suspicion. Among these reputed signs may be mentioned: black lines under the eyes, pallor of the cheeks, inflammation of the eyes, &c. Generally speaking, it must be said that in sexually immature children nothing but direct observation will justify a definite diagnosis of masturbation, except in cases in which the child itself makes confession to someone in its confidence. For the diagnosis of auto-erotism, however, it is not necessary to establish the occurrence in the child of the voluptuous acme; it suffices for this diagnosis if there occur signs of those general voluptuous sensations which were described on page 58. In many cases in which the practice of masturbation is diagnosed, and in cases in which children themselves confess to masturbating thirty times a day or more, we can hardly suppose that the voluptuous acme or orgasm is attained. It is sometimes maintained that the early appearance of the physical manifestations of puberty is an indication that psychosexual processes are also occurring prematurely. Thus, Kisch[81] expresses the opinion that in many cases premature sexual development manifests itself in children by the enlargement of the breasts, and by the growth of the axillary and pubic hair, in the absence of the commencement of menstruation, Kussmaul also observed cases in which, in comparatively early girlhood, all the physical signs of puberty were present although menstruation had not yet begun. According to my own experience, we must be careful to avoid taking an exaggerated view of such a connexion. Passionate psychosexual processes may occur in young children in the absence of any physical signs of premature sexual development. An impulse to masturbate may also arise quite independently of the commencement of the adult development of the external genital organs. Psychically determined erections may likewise occur, although the physical development is by no means far advanced. We shall therefore do wisely to avoid taking a narrow view of such a connexion, inasmuch as it may be that the physical signs of puberty on the one hand, and the phenomena of detumescence and contrectation on the other, may occur in conjunction at a very early age, whilst, in other cases, phenomena of the one class or of the other may occur in isolation. This statement is true, not merely of the secondary sexual characters, whose development by no means always affords a measure for the degree of development of the sexual impulse, but it is true also of the reproductive organs themselves. Halban[82] reports the case of a boy six years of age, whose penis was as large as that of a full-grown man, but in whom, apart from the erection, all the characters were infantile. Still more often do we note the independence in many young men of the individual symptoms of sexual development from the growth of the beard, for this latter is