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 often still lacking at an age when the sexual life in general has attained an extensive development. Still less importance must be attached to other occasional signs. According to Marc d'Espine[83] "puberty occurs early in girls with dark hair, grey eyes, a delicate white skin, and of powerful build; late, on the other hand, in girls with chestnut hair, greenish eyes, a coarse, darkly-pigmented skin, and of delicate, weakly build;" but the evidence to justify any such generalisation is lacking. It is possible that the opinion quoted is supported to some extent by certain associated racial peculiarities, but we must be on our guard against accepting inferences of too sweeping a character. Still less, of course, are such peculiarities a trustworthy aid for the diagnosis of the occurrence of sexual acts at an early age.
The safest way of obtaining accurate information as to the practice of masturbation and other sexual acts is by means of confessions made to some person in the child's confidence. Cases are known to me in which children have very readily confided in some elder person. If this does not often occur, the fault commonly lies with the child's elder associates, who do not understand how to establish a truly confidential relationship with the children under their care. If a child finds that no one will speak to it about sexual matters, it must ultimately become secretive about its own sexual life. The child sees very clearly that every word it utters about such things is repressed as improper, and soon learns that the whole field of sexuality is regarded as something unclean, about which not a word must be uttered. The ordinary behaviour of adults inevitably produces this impression in the child's mind, and it will readily be understood what an effect this has in preventing us from gaining information about the sexual life of the child. In many mothers, the abhorrence of the sexual is carried to such an extreme that while in other respects they keep their children scrupulously clean, they feel so strongly that the genital organs must not be touched, that they neglect to secure the ordinary cleanliness of this region of the body.
The best confidant for a young child will usually be the mother, not only because she sees more of the child than the father and because her relationship is a more intimate one than his, but in addition because a woman's insight into certain things generally excels a man's. As a matter of fact, for the reasons stated, masturbation in young children is in most cases discovered by the mother. It will be obvious that I speak here only of those mothers who have real affection for and sympathy with their children, and who share their children's interests; I do not refer to those mothers who think they have adequately fulfilled their maternal duties by paying a nurse or a governess, whilst themselves immersed in the pleasures of society—or perhaps engaged in the preparation and delivery of lectures on the best way of bringing up children, on the Woman's Movement, Woman's Suffrage, and similar topics—or, it may be, attending these same lectures—those who, in any case, prefer some other occupation to the care of their own children.
Above all, let not those who have the care of children be deceived, either by diligence, or by conduct exemplary in other ways, or indeed by earnest study of the Bible, by pious protestations, or by regular attendance at church. I know a boy of twelve, reputed to be extremely religious, and ostensibly on religious grounds going to church every Sunday; but whose real motive in the church-going was the hope to meet the girl of whom he was enamoured. Extensive experience of the conduct of adults should teach us the necessity for extreme caution in these respects. I recall the case of a gentleman whose reputation was that of a paragon of all the virtues. When others of an evening went out to enjoy a glass or two of beer, or in search of even lighter pleasures, he was supposed always to turn homewards, ostensibly in order to work. Only after some years was the fact disclosed that he was an habitual loose-liver, enjoying indiscriminate sexual intercourse with unmarried girls and with his neighbours' wives, although to his friends and comrades he had appeared to be a man of exceptionally strict life, and this above all in sexual relationships. The same may be true also of quite little children. Hebbel relates that in his first year at school be sat next to a boy who appeared to be engaged in the most earnest study of the catechism, whilst under the rose he was pouring into young Hebbel's ear all kinds of obscenities, and was asking him if he was still stupid enough to believe that children were brought by a stork or were found in a basket in the cabbage-patch. Many parents, too, know so little about their children in these respects, that they are utterly astonished when some day their eyes are opened to the facts of the case by their family physician. I knew a boy of fourteen who went regularly to church, and who in other respects was a fine fellow, and a diligent pupil at school He was brought to see me because he was affected with spasmodic movements. On examination, I found him to be suffering from a severe attack of gonorrhoea, which he had contracted in intercourse with his aunt's servant-maid. When I told his mother the truth, she was at first extremely angry at what she was convinced must be a mistake on my part; but further inquiry disclosed the fact that for a year or more the boy had been intimate with prostitutes and other girls.
I have been writing of processes occurring in the reproductive organs, such as erections, seminal and other discharges, and masturbation; and of the means for the recognition of these processes. But it is necessary to recognise that we must not assume without further inquiry that all processes occurring in the genital organs are of a sexual nature, although in individual instances the distinction between the sexual and the non-sexual may be extremely difficult, or even impossible. Thus, of erections occurring before the reproductive glands ripen, not all are of a sexual nature. We know, too, that even in the adult, non-sexual erections may occur. The clearest instances of this are met with in the form of priapism, the principal characteristic of this condition being the occurrence of permanent erection which has nothing at all to do with the sexual impulse. The same is true for the most part of matutinal erections, the precise cause of which is not yet determined. They are commonly referred to distension of the bladder, which is supposed by reflex action to lead to distension of the corpora cavernosa of the penis. It is certain, at any rate, that these matutinal erections are not caused by sexual thoughts, nor as a rule do they induce sexual feelings. We must distinguish between these processes; just as recently we have learned to distinguish herpes progenitalis, the characteristic of which is its localisation to the genital organs, from herpes sexualis, which is directly dependent upon sexual processes. If we regard this distinction between sexual and non-sexual erections as applicable also to erections in childhood, we are justified in assuming that many erections, in infants-in-arms, for instance, are non-sexual in nature, even though in appearance there is nothing to distinguish them from sexual erections. In infants, erections may arise from external stimuli or from distension of the bladder, which must be distinguished from the erections which have a definitely sexual causation. We must, of course, admit the possibility that such primarily non-sexual erections may secondarily give rise to sexual processes; inasmuch as by the stimuli resulting from the erection, the child's attention may be directed to the genital organs. Just as we must guard against regarding every erection in the child as a sexual process, so also must we be cautious in our estimate of the significance of manual stimulations. Children often stimulate various parts of the body. Some children will rub the lobule of the ear, others will suck their fingers, or will stimulate their mouths in other ways. Some children have the offensive habit of picking their nose; and it is evident that many cases in which children stimulate the genital organs manually are on the same footing with nose-picking and numerous similar habits. In such cases we have not to do with a specific genital sensation to which the child responds; but with a stimulus which may be pathological, but is not necessarily sexual. In many cases, indeed, the stimulus is not even pathological. We have to take the following point into consideration. As soon as the child begins to become conscious of the existence of its organs, it fingers them. It does this with its nose and its ears, just as it does with its feet; and it is obvious that the genital organs will receive the same treatment. A gentleman who had grown up in the country related to me that as a child he had often been present when cows were being milked, and that in the evenings, after he had gone to bed, he performed the milking movement on his penis, and was greatly astonished at the fact that no milk flowed forth. He assured me that the like experience had occurred to quite a number of boys who had been his playmates in the country. It is certain that such manipulations of the genital organs, entirely non-sexual in origin, may lead to the practice of masturbation. But we must not immediately conclude that every manipulation of the genital organs in a child is sexually determined.
It is true that many investigators regard numerous movements on the part of children as sexual processes, even when the genital organs are in no way involved. Freud[84] above all, discovers sexuality in the life of the child in cases in which, I am convinced, sexual elements play no part whatever. Sucking movements in children are regarded by Freud as sexual phenomena. He considers that the lips and the fingers are erogenic zones. With just as much reason, every movement might be regarded as sexual—as, for instance, the clenching by a child of its little fists. As long ago as 1879, Lindner,[85] of Budapest, published an able essay about the movements made by children sucking their fingers, lips, &c., and suggested that there was some connexion between these sucking movements and sexual processes. He stated that many children, when sucking the lips, the fingers, the back of the hand or some other part, or when sucking a rubber teat, simultaneously rubbed some other region of the body—in some cases the lobule of the ear, the nipple, or the genital organs; this was sometimes done with one hand only, sometimes, if both hands were free, with both. This statement is perfectly correct. It may happen that the child stops rubbing the genital organs as soon as the sucking is interfered with; or, conversely, the sucking may cease as soon as we withdraw the child's hands from its genital organs. But, even in these cases, the friction of the genital organs does not necessarily possess a specifically sexual character, since friction of the lobule of the ear or of some other part of the body is an equivalent act. It is certain that there is here no intimate connexion between the act of sucking and the sexual life. Thus, there is no proof whatever for the view of Lindner, which has recently been carried to a still greater extreme by Freud, that this "voluptuous sucking" (Wonnesaugen) is a truly sexual process. We may, indeed, assume, as does Rohleder,[86] that such sucking movements occur with especial frequency in children with a congenital morbid predisposition, and that to this extent therefore it is connected with masturbation. But in my opinion it is essential to regard the two movements as clearly independent in character.
Certain other childish habits, such as nail-biting, have also been described as sexual manifestations. What I have said of sucking movements applies to this also. It is true that nail-biting and masturbation may both occur in the same child, and French writers have maintained that there is a causal nexus between the two processes. If we regard nail-biting as a "tic" occurring chiefly in neuropaths, and if we assume that the neuropathic congenital predisposition is the basis of the premature awakening of sexuality, it may be supposed that to that extent there exists a relationship between the two phenomena, inasmuch as we may refer both manifestations to a common cause, viz., the neuropathic predisposition. But there is no justification whatever for regarding, as some do, one manifestation as the direct consequence of the other.
Speaking generally, we shall do wisely to exercise caution in defining the limits of the sexual life of the child. If a boy runs after a girl, and if the two flirt one with the other, it will often be merely from a desire to imitate their elders. In many instances, even, in which the genital organs play a part in such imitation, we must distinguish what is done from the sexual life proper of the child. If children play at "father and mother," if the "midwife" comes, and "childbirth" takes place, the play may certainly depend upon an early awakening of the sexual life; but this is not necessarily the case. There may be no more than innocent imitation of grownups, as the following case shows. A number of little boys and girls, almost all under eight years of age, played at being prostitutes, souteneurs, and men-about-town. The little girls each demanded a penny when they had allowed the little boys to touch their genital organs. It was an extremely characteristic fact that the leader of this band was a feeble-minded boy, whose parents I had advised to send him to an asylum, because, after various dangerous actions, he had attempted one night to kill his little sister eighteen months old by inserting beans in her nose. Such acts as that first described may, of course, depend upon a premature awakening of the sexual impulse; and when a number of children engage in amusements of this kind we not infrequently find that in the leader and seducer the sexual impulse is already awakened, whilst the others act merely in obedience, at first, at least, to an imitative impulse. Certainly, I have known a few instances in which children with premature sexual development very rapidly came to a mutual understanding, and in whom their intimate association was dependent upon prematurely awakened sexual impulses.
Just as sexual acts in which the genital organs play a part occasionally arise, not from premature awakening of the sexual impulse, but from imitation merely, so also, as previously explained, may this happen in the case of more harmless processes. Braggadocio here plays a great part, and also the desire to act like grown-ups. Thus, the boy who runs after girls, and makes appointments with them, sometimes does this merely to show off before his companions, and to produce in them the impression that he is a "manly" fellow. We must take care to separate these cases, also, from those that are genuinely sexual.