Without any good reason in the etymology or the history of the word, the term "tics" has now been generally accepted to signify certain involuntary movements, frequently recurrent, of which, by habit, certain persons usually of diminished nervous control, become the victims. For the psychotherapeutist, however, they have an interest quite beyond that which they have for the ordinary student of nervous diseases. They represent the possibility of the formation of habits in the nervous system, originally quite under the control of the will, but which eventually become tyrannously powerful and quite beyond management by the individual. They deserve to be studied with particular care because it is probable that they represent objectively what occurs also on the sensory side of the system, but which not being manifest externally, is spoken of as entirely subjective. If nerve explosions of motor character can, through habit, get beyond the control of the patient, it is not unlikely that sensations, primarily of little significance, may, in persons of low nervous control, become by habit so likely to be repeated as to make the patient miserable. Hence the study of tics as here presented.

As a result of the studies of Gilles de la Tourette, we realize that there is an essential distinction between involuntary movements of various kinds, and that spasms and tics must be separated from one another. Tics consist of various movements of the voluntary muscles. Probably the most familiar {565} is that of winking. Everybody winks both eyes a number of times a minute quite unconsciously, though the unconscious movement accomplishes the definite and necessary purpose of keeping the conjunctiva free from irritant particles. When this same movement is done more frequently than is necessary, or is limited more to one eye than to the other, or is repeated exaggeratedly in both eyes, then it is a tic. There are many other facial tics. Most of them represent movements of the lips or of the nose or of the skin of the forehead and all of them are identical with movements that are occasionally performed quite voluntarily. There are movements of the lips as in sucking, or smacking sounds may be made, or such movements of the features as are associated with sensations of taste or smell. Sometimes changes of facial expression may be tics and without any reason there may be recurring expressions of emotion, of joy, or grief, or fright, or even pain. Sometimes the tics affect structures that are internal, as various motions of the larynx accompanied by the production of grunting or sighing sounds or sometimes even of particular words. In children the tendency is prone to manifest itself in the utterance of forbidden words, usually vulgar, sometimes indecent.

Besides these facial and throat tics any of the voluntary muscles of the body may be affected. There may be the gestures that accompany certain mental states, or there may be twisting or turning movements as if the patient were in an awkward position and wanted to get out of it, or as if the clothes were hampering movement and there was an effort to relieve some discomfort. The head may be lifted and lowered, or may be twisted from one side to the other and, indeed, various nodding tics are extremely common. Almost any ordinary movement may, in nervous people, come to be repeated so frequently as to be a tic.

Practically all of the convulsive or quasi-convulsive movements associated with respiration are likely to become the subject of tics. Yawning, for instance, involuntary to some degree, usually a reflex with a physical cause, but so readily the subject of imitation, may become so frequent as to be repeated a couple of times a minute and this repetition kept up for many days. Sneezing may also become a tic, though it is usually a definite reflex due to palpable physical causes. Hiccoughs may easily become the subject of a tic. The occurrence of a persistent hiccough is in popular medicine a sign of unfavorable prognosis in serious diseases, especially such as involve the abdominal region. In connection with neurotic affections of the abdomen, however, hiccoughs are not uncommon and are of no serious significance.

Varieties of Tics.—There are many more tics than are ordinarily supposed. Indeed, there are few of us who escape them entirely. Nearly all the curious phrases that people interlard so frequently into their conversation, usually quite unconscious of them, or of the ridiculous significance they often have, must be placed under the tics. Some men cannot say a dozen words without interpolating "don't you know." Others use some such expression as "in that way." I once knew a distinguished professor of elocution who by actual count used this phrase forty times in an hour. Some say "hum" or "hem" every sentence or so. Whenever there is a bit of obscurity in their thought these voluntary but unconscious expressions are sure to pop out. No one who has had much experience in public speaking ever succeeds in keeping entirely out of such bad habits. It is curious how phrases will insist on repeating {566} themselves. One year one set of words, or a pet phrase, or mode of expression, creeps unconsciously here and there into an address. Then either because the speaker has been reading dictated copy, or because some good friend has the courage to tell him of it, he finds out the bad habit and suppresses it.

Word formulas senselessly repeated are only one of many forms of tics that public speakers are prone to indulge in. Gesture which begins as an artificial adornment of speech, very appropriate in itself, after a while may settle down into certain forms that not only often lack elegance but that are really disturbing to an audience. Of these gestures and movements men are often quite unconscious. They have become habitual and in the absorption of mind with the thought and the words, they are reproduced quite involuntarily though they are all originally voluntary movements. Nearly every public speaker needs a mentor to correct him of such faults. It is rather difficult to break some of these habits and it requires no little concentration of effort and attention to be successful in eradicating them. It can be done, however, provided the habit is not too inveterate, and this is the best evidence that tics of other kinds can also be eradicated if the patient really takes the matter in hand and is not of a weakened will.

Teachers' Habits.—Indeed it is almost impossible for public speakers and teachers not to acquire certain habits irritating to their auditors at first but amusing as they grow used to them, and students particularly learn to look kindly at the ridiculous side of many of them. I remember an old professor of literature who used to lecture at some length on each of the important contributors to English prose and poetry. We soon observed that whenever he came to their deaths he took out his handkerchief and blew his nose. This was as inevitable and as invariable a rule as the laws of the Medes and the Persians. It was, as it were, his tribute of sympathetic condolence with humanity for the loss of a brilliant contributor to English literature.

Occasionally the effort to break up these habits will seriously interfere with modes of thought and habits of expression, for the time being at least. A professor at a certain university had a habit every now and then of plucking at a button on his coat. His students could tell when his hand was going to find this object of its occupation and knew from experience that he would twist it a certain number of times. He was not what would ordinarily be called a nervous person. One day he happened to take off his coat shortly before a lecture and one of the students surreptitiously removed the button. At the end of the first few minutes of his lecture his hand went up to find the button as usual but failed. For the moment there was a hesitancy in his speech; then he tried again. A little later his hand went up unconsciously and was disappointed; then he stammered and lost the thread of his discourse. The last half hour of that lecture was seriously impaired because of the absence of that button.

Tricks of Speech.—There are many other curious tricks of speech that are really tics. Women often indulge in them and sometimes even pretty women spoil their appearance by bad habits. All of us know the pretty woman who talks very fast, but who every now and then projects her tongue a little beyond her teeth. Occasionally there is a tendency to wrinkle the nose or the forehead. Most of us have seen the woman who sets her face into a definite smile of a particular kind whenever her company manners are in {567} use, though there is a vacancy behind the smile that is rather disturbing. Some people have habitual movements of the fingers that are really tics, and even positions assumed on sitting down that are very ungraceful, or that are very noticeable, sometimes partake of this character.

Fussiness.—A very common form of tic that is quite difficult to control is that tendency to be doing something with some of their muscles which characterizes many men. They must handle a pencil or a knife, or they must swing on their chair or tilt back on it, or keep one of their limbs swinging over the other, or twirl their moustaches or stroke their beards, or rumple their hair, and they cannot find it quite possible to sit still. The difference between men and women in this regard is remarkable. Women are conceded to be much more nervous than men, but men are ever so much more fidgety than women. The author of "The Life of a Prig" in his book "The Platitudes of a Pessimist" has some striking paragraphs with regard to this subject. He says:

To look nearer home, the British bar affords splendid examples of nervous fidget. Observe barristers pleading a cause. How they torture a piece of red-tape, how they twirl their eye-glasses or spectacles, and how they hitch at their garments, as if they momentarily expected them to desert their finely proportioned figures. But worse than the Queen's Counsellors, and even worse than the domestic peripatetic, is the villain who is abandoned to a performance vulgarly known as "the devil's tattoo"—drumming with the fingers.

Writers' Tics.—Writers, and above all writers for the daily press and such as have to do their writing in a rush and therefore get nervous and anxious about it, are especially prone to develop tics, though others who write leisurely may do so. Some of these are curious and others are only expressions of nervousness common to all people. Many of them chew their nails, some of them bite at their fingers round the nails and make them sore, many of them chew the ends of their pens and find it practically impossible to keep a pen with a long handle to it. Some of them run their hands through their hair until it is in a greatly rumpled condition, some of them pluck at their eyebrows. I have one patient who when he is going through a particular nervous strain plucks out the middle portion of his right eyebrow so that he has a distinct bald spot at this point.

The tradition in newspaper offices is that these curious expressions of the tendency of the body to occupy itself with something while the mind is occupied are more or less inevitable in nervous people. They continue for many, many years. They are only habits, however, that it would have been rather easy to break in the beginning, though they become extremely difficult to modify after they have once secured a firm hold. Occasionally I have fastened a piece of adhesive plaster over a much battered eyebrow, but that made it difficult for the man to go on with his work. His hand would go up involuntarily time after time and while plucking at his eyebrow would not disturb in the slightest his train of thought, just as soon as his fingers touched the unusual object a serious distraction occurred and work was not only slower, but much more difficult.

In Games.—The tendency to the formation of curious habits of associated movements can be seen very well in most games where skill is combined {568} to a certain degree with chance. It is most noticeable, perhaps, in bowling. Few men are able to restrain themselves from making some special movement just as the ball strikes the pin. This is sometimes a motion of the head, oftener it is a jerk of the trunk, sometimes it is an associated movement of the arms, occasionally it is a kick or a stamp. In billiards the same movements are noticeable if a man is much interested in making a difficult shot. Usually there is some movement of the body or of the hands or of the head that would indicate his desire to move the ball in a particular direction. Women who play these games do not usually have these associated movements to such a marked degree and this may be due either to their better restraint to movement in general, for as we have said men do not acquire the habit of self-restraint in small matters of deportment as women do, or to the fact that such associated movements might disarrange their clothes. Perhaps, also, they are not as much interested in the games as a rule as are the men. Of course, similar associated movements may be seen in outdoor sports that require skill yet have an element of chance in them. For it is, as it were, to overcome this that the additional movement is made.

Children's Tics.—Some tics consist of some very curious habits. Occasionally children hear some obscene or vulgar expression and repeat it. The repetition of it produces such a look of shock to propriety on the part of some of the other little ones who happen to be present that they repeat it in the spirit of bravado and then continue to utter it until it becomes a habit that is hard for them to break. After all, the use of blasphemy later on in life is really a tic, a habit of uttering words no longer expressive of any particular feeling, as a rule, unless in exceptional circumstances but just the result of a tendency for the speech organs to repeat certain words. They tell a good story of the Rev. Sydney Smith who, wishing to break an acquaintance of the habit of indulging in expletives, interlarded his speech with "fire tongs and sugar tongs" every ten words or so and when his auditor protested that that added nothing to the significance of what he said the Rev. Sidney suggested that that was also true of various blasphemous expressions that his acquaintance was accustomed to use.

At the SalpÊtriÈre they tell the story of a little boy who had the habit of saying the French word which the corporal in Victor Hugo's "Les Miserables" made use of when anyone told him that it was because Wellington was a greater general than Napoleon that the French Emperor was defeated at Waterloo. Nothing seemed to be able to break the boy of the habit of interjecting this word into conversations sometimes in which he had no part and sometimes toward which he was expected to take only a respectful and childlike attitude of silence. He was sent to the SalpÊtriÈre. The ordinary remedies had failed entirely. One day he was allowed to go outside of the hospital, or rather stole out of the gate and played marbles with some street gamins in front of it. During the game he used the word in question and they proceeded to give him a good thrashing. It is Charcot who tells that this broke him effectually of the habit.

One of the childish customs that sometimes disturbs parents very much because it seems to be such an unaccountable lapse into barbarism, though it is really nothing more than a tic in the strict sense of the word, is the habit that some children acquire of removing portions of hardened material {569} from their nose and then putting it into their month. Refined parents are apt to be so seriously disturbed by this that they fear for the child's mentality. Really the habit is not nearly so rare as is usually thought by some grown-ups who have forgotten about their own and others' childhood. In country places the habit is very common. It is not alone the dull children who do it but some very bright ones. Indeed, the tendency to the habit is so common that one wonders whether there is not something in nature that tempts to it. Parents who are fearful lest their children may be seriously hurt in health by the awfully insanitary habit may be reassured that after all a certain amount of the drainage of the nose is normally carried off through the posterior nares to the stomach and that no danger to health seems ever to have resulted from the practice. As a rule, the habit can be broken rather easily by a little judicious care and insistence, though I know of cases where relapses occurred and the habit continued surreptitiously.

Motor Tics.—Motor tics frequently develop as a consequence of some injury to a nerve or some intense overuse of it. Winking habits follow an herpetic involvement of the superior branch of the fifth nerve. Bell's palsy is sometimes followed in the face by a tendency to twitching on the unaffected side that makes the patient quite uncomfortable. Herpes zoster is sometimes followed by a catching of the breath, probably due to a little spasm in the muscles supplied by the nerve thus affected. Some of the yawning tics have this origin. Any neuritis may in the course of its betterment be followed by this curious tendency to explosion along the nerve that has been affected, as if the pathological process had more seriously interfered with inhibition than with the actual function of the nerve. Examples of over-exertion followed by twitchings are not rare. A scrubwoman who has seen better days and now has to carry a heavy bucket and use her right hand much with the brush may develop a twitching of the right arm. A janitor's wife who sweeps much may have a tendency to twitchings of the fingers as a consequence of the unusual exertion of holding the broom. Twitchings in the limbs of men who work at a foot lathe or other machine requiring foot power are not unusual though they are more often seen in the leg on which the workman habitually stands than in the other one and it seems to be oftener a strain on muscles than actual over-exercise that precedes the development of these tics.

Heredity.—Heredity plays as large a role in tics as it does in stuttering and other functional nervous disturbances. Occasionally the direct inheritance of some habit will be found, though there is nearly always more than a suspicion that a trick of speech or of act, which constitutes the tic, was learned by imitation rather than transferred directly. Besides, it is a case of a similarly constituted nervous system reacting in the same way to a similar environment, rather than any definite tendency existing by heredity in the nervous system. It is surprising what close observers children are and how easily they learn to imitate any habitual action of father or mother or, for that matter, of nurses or those who are close to them.

Mental Treatment.—The most important element in the psychotherapy of tics is their prophylaxis. They run in families, not by any inevitable hereditary influence, but as a consequence partly of imitation and of corresponding tendencies resulting from certain weaknesses in the family. Wherever they are known to be likely to occur, parents should be warned of the {570} possibility and the first symptom of any motor habit should be considered the beginning of a tic. As we have said, they are likely to begin in muscles that have been overstrained for any reason, especially when patients are run down. They are often seen after herpes and certain facial neuralgias.

There is probably no tic, no matter how long or how serious, that can not be eradicated, or greatly modified, if the patient will take the trouble and if the treatment is conducted so as gradually to get rid of it. Peculiar movements cannot be done away with at once. They can be lessened in intensity and in frequency and then gradually the patient will be encouraged by their becoming less noticeable than before to make renewed efforts. The habit must be gradually undone and this will take as long as it did to form it originally. The exercise of contrary muscular movements carefully carried out, and of gentle repression with definite times of exercise during the day, gradually increasing the length of the intervals of repression, in the end proves successful. Only a determined struggle will effect a cure. It depends on the patient's will. Like a drug addiction, or a tendency to overeat, or a craving for alcohol, it must be gradually overcome and then care must be exercised to prevent relapses; for when the condition is somewhat better, to relax vigilance and give up effort will allow the old condition to reassert itself with startling rapidity. People suffering from severe tics will often give up. Without the patient's hearty co-operation cure is impossible. With good will its gradual diminution gives the patient a confidence in self and an uplift in character that is extremely valuable, not only for physical but for mental conditions.