Page 20 - Summer 2024 Bulletin

Medical History
If I Had a Hammer
S. Aaron Laden, MD, MBA nedalleumas@yahoo.com
Those of a certain age recall the time in 1963 and subsequent years when radio stations continually played the hit song “If I Had a Ham- mer,” by Peter, Paul, and Mary
If I had a hammer, I’d hammer in the morning
I’d hammer in the evening all over this land
It seemed as if it were a reflex for radio disc jockeys to queue up that platter.
Meanwhile, most doctors did have a hammer, and it was like a reflex to use it for neurological examinations.
For a physician to test a pa- tient’s reflexes, it was first nec- essary to know that they existed. The idea originated in 1875 with the elucidation of deep tendon re- flexes by German physicians Wil- helm Heinrich Erb (1840-1921), a neurologist, and Karl Frederic Otto Westphal (1833-1890), a psychiatrist, pursuant to their study of tabes dorsalis.
Why, you ask, would any doc-
tor think that it might be a good
idea to strike a patient with a
hammer? At the time doctors
began testing deep tendon reflexes, they had already been striking patients with hammers for decades. They used per- cussion hammers to check for fluid in the chest cavity and for examination of the abdomen. The practice is said to have derived from the use of percussion hammers by vintners to determine the volume of wine in a cask or barrel. Of course, we are not referring here to a ball peen hammer or to the carpenter’s claw hammer. The percussion hammer was a delicate, precision instrument.
The first physician to popularize percussion for diagnos- tic purposes may have been Leopold Auenbrugger (1722- 1809), a Viennese who described as early as 1761 the pro- cess of percussion of the chest and abdomen using fingers to
strike the chest wall and to assess the condition of internal organs by the sounds produced.
In 1826, Pierre Adolphe Piorry (1794-1879), a Parisian physician, introduced the idea of using a pleximeter to am- plify the sound. A pleximeter is a piece of solid material such as ivory or wood interposed between the chest wall and the striking finger.
Early on, reflexes were tested by percussion with the phy- sician’s own hand, often by striking the tendon with a finger or with the ulnar surface of the hand. However, the use of a hammer was quickly adopted. As noted above, such tools had long been in use for examination of chest and abdomen by listening for the quality of the sound produced.
Already having the percussion hammer in the physician’s arse- nal, it quickly became common to use that same hammer in the neurological examination. An early popular percussion hammer was that of Max Wintrich (1812- 1882), a German physician. It was widely used both for percus- sion and auscultation but also be- came popular for reflex testing.
Percussion hammers were of- ten too delicate for effective mus- cle tendon reflex testing. The first widely used hammer designed
specifically for tendon reflexes is believed to be the design of John Madison Taylor of Philadelphia who, in 1888, intro- duced the familiar hammer consisting of a rubber triangle with metal handle. This model had the additional advantage of a wide edge simulating the ulnar surface of the hand and a narrow end imitating a fingertip. It was originally designed with a wire-loop handle, but the modern version sports a solid, pointed handle useful for eliciting cutaneous reflexes.
Once the efficacy of the reflex hammer was demonstrat- ed and became widely available, there followed numerous “new and improved” versions. See Figure 1. They varied in size, weight, design, and materials of construction, in- cluding those using iron, bamboo, or whale bone handles.
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HCMA BULLETIN, Vol 70, No. 1 – Summer 2024