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ABSTRACT
RESUMO
Descritores: Martelo; Neurologia; História; Reexos.
IMAGES
The neurologist’s hammer
O martelo do neurologista
E
duardo Nogueira
1
Yara Dadalti Fragoso
1
Neurologist’s hammer
1
*Correspondence
Yara Dadalti Fragoso
E-mail: yara@bsnet.com.br
Received: December 12, 2019.
Accepted: December 20, 2019.
From the obscurity of 18
th
century wineries to the hands of the greatest
neurologists in history, the percussion hammer has a fascinating history. The
rst famous percussion hammer was created in 1841 by the German physician
Max Wintrich and was initially used for thoracic percussion. In 1875, Erb and
Westphal both published simultaneous articles with the results from research
that they had conducted separately, from which they conrmed that percussive
objects were useful for stimulating deep tendon reexes, especially patellar
reexes. The percussion hammer, however, was not yet ideal. It was designed to
strike the thorax rather than the tendons, so it did not have the right weight or
ideal length, and even its shape was not practical. New modied versions of the
instrument subsequently emerged, and the hammer became the characteristic
symbol of the neurologist.
Keywords: Hammer; Neurology; History; Reexes.
Da obscuridade das adegas do século XVIII às mãos dos maiores neurologistas
da história, o martelo de percussão tem uma história fascinante. O primeiro
martelo de percussão a ganhar notoriedade foi criado em 1841 pelo médico
alemão Max Wintrich, sendo inicialmente usado para percussão torácica. Em
1875 Erb e Westphal publicaram em conjunto um artigo com os resultados de
suas pesquisas, que foram realizadas separadamente, conrmando o uso dos
objetos de percussão para o estímulo dos reexos tendíneos profundos, em
especial o patelar. O martelo de percussão, contudo, ainda não era o ideal.
Por ter sido desenvolvido para percutir o tórax e não os tendões, ele não tinha
o peso certo, o comprimento ideal e nem mesmo um formato prático. Novas
versões modicadas do instrumento foram surgindo até que o martelo se
tornasse o símbolo característico do médico neurologista.
Headache is one of the
neurological complaints that leads
a patient to seek urgent care more
often. Although it seems a common
issue the patient should be submitted
through a very careful and detailed
physical examination (including
neurological examination) so redag
symptoms and secondary causes of
headache can be excluded.
For that matter the percussion
hammer is an indispensable tool
for the neurologist and general
practitioner.
Percussion is an aid to medical
diagnosis. The delicate percussion
hammer neurologists use daily has
its origins in the dark wine cellars
of 18
th
century Austria, where young
Leopold Auenbrugger routinely
struck casks of wine in order to
check the level of uid
1
. As a music
admirer, he had sensitive ears and
wrote the axiom “the thorax of
a healthy person sounds, when
struck”. Auenbrugger favored
thumping his patients’ chest directly
with his own ngers, as most doctors
still do today
1
.
The rst percussion hammer
for medical use was created by
Max Wintrich, in 1841. This German
doctor presented the scientic
world with his gadget made of
steel and rubber, for use in thoracic
percussion (Fig 1)
2
. However, it was
only in 1875, when Carl Westphal was
the Editor of Archiv für Psychiatrie
The neurologist’s hammer
Nogueira, E, et al.
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Headache Medicine, v.10, n.4, p.205-207, Out/Nov/Dez. 2019
und Nervenkrankheiten (“Archive for Psychiatry and
Nerve Sickness”), that the hammer for eliciting reexes
was created. While reviewing a paper by his colleague
Wilhelm Erb, Westphal was astonished to see that
Erb had reached conclusions that were rather like his
own. Separate articles from Erb and Westphal were
published in the same issue of Archiv für Psychiatrie und
Nervenkrankheiten
3, 4
.
Erb wrote: “If one rmly holds and supports the
leg to be examined, slightly bent at the hip and knee
joint with all the muscles relaxed, and then lightly and
elastically taps the region of the ligamentum patellae
with the nger or with the percussion hammer […] each
tap is immediately followed by a slight but signicant and
evidently reex contraction of the quadriceps; […] and it
is extremely difcult to suppress this reex voluntarily”.
Westphal wrote that the idea of tendon percussion was
given to him by one of his patients who said that when
he sat on a chair and lightly tapped the area below
the kneecap of the affected leg, it moved forwards
with a sudden jerk. While Erb described in detail how
to elicit the patellar reex with a percussion hammer,
Westphal described nger percussion, but mentioned
that a precision hammer would be more effective in this
maneuver
5
.
Thus, Westphal and Erb started the history of the
neurological percussion hammer. This history continued
with the arrival of different models of this tool for
neurological examinations. New modied versions of the
instrument emerged over the course of the nal years of
the 19
th
century
6
. Schematic images of some percussion
hammers are shown in 1.
Some of these hammers gained small gadgets like
a needle with sharp and blunt points inserted into the
handle, a small brush, or even a ruler or Wartenberg
wheel. In 1888, John Taylor introduced the rst reex
hammer with a triangular shaped head made of rubber
circled by a metal band. It had a metal handle nishing in
a loop and was manufactured to order by the Snowdon
Brothers Instruments Company
7
. Around 1920, the
loop was replaced by solid metal, giving this percussion
hammer the shape that we all know so well.
In 1894, William Christopher Krauss devised a model
that had two rounded pieces attached to a metal. The
large piece was designed to be used for the knee jerk
and the small one for the biceps jerk. The warm rubber
handle, the cold metal head, the sharp and blunt pin
heads and the brush would help in testing sensitivity
2
.
Ernst LO Trömner introduced the metal handle tapering
to a thin end, in order to test cutaneous reexes as well.
The Vernon hammer consisted of a rubber disk around a
metal sphere.
The Queen Square Hospital and Babinski hammers
followed, comprising a rubber disk around a at metal
disk
7
. The main difference between these lies in their
ease of carrying, since Queen Square is rigid, while
Babinski is smaller and telescopic, with a shorter handle.
Even if some consider these to be similar, Queen Square
is almost 150 grams heavier than Babinski
2
. The Queen
Square Hospital hammer was developed by Miss Wintle,
a nurse at the hospital.
The Rabiner hammer has a rubber disk that can be
used in parallel with or perpendicular to the handle, as well
as an inserted brush and needle for supercial reexes
Figure 1. Drawings from different neurologist’s hammers
The neurologist’s hammer
Nogueira, E, et al.
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Headache Medicine, v.10, n.4, p.205-207, Out/Nov/Dez. 2019
and sensitivity assessment. The history of the Rabiner
hammer is quite peculiar. Babinski and Rabiner had an
argument about the physiology behind the Babinski
reex. The argument occurred during a black-tie dinner
in Vienna and the two neurologists became physical,
pushing and shoving each other to the amazement of the
dinner guests. The dispute was settled and, as a token of
respect and apology, Babinski gave his own percussion
hammer to Rabiner who returned to New York and
modied its shape and appearance
2, 7
.
With the rubber disk attached to the handle at 90
degrees, the Berliner hammer looks like a throwing axe.
The Stookey hammer is collapsible and is accompanied
by a camel hairbrush and two sharp pins for testing
supercial sensitivity, including two-point discrimination.
In addition, the Stookey hammer has a rough structure
to test the plantar response
6, 8
. The ve-in-one hammer
includes a tuning fork and a Waterberg wheel. The
Dejerine hammer features a hollow metal handle with
inserted hick brush and needle, and a double rubber
head. Imaginative improvements to this tool continue to
be made. Neuropediatric wards nowadays have a variety
of animal-shaped and colorful percussion hammers.
Although the hammer was initially developed for
percussion of the thorax and abdomen in medical practice,
it has now become the hallmark of the neurologist.
Purists among the practitioners of the art of neurological
examination will favor one hammer or another. The
present authors have their favorite ones as well, but we
do not feel like arguing about this. Use of a percussion
hammer is a matter of personal taste and experience: one
of these situations in which there is no right or wrong.
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4. Erb WH. Über Sehnenreexe bei Gesunden und
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