Perspectives
Object lessons
Reflex hammer
Medical students were traditionally taught that, in their
initial encounter with their patients, gastroenterologists
relied mostly on the patient’s history and neurologists on
the physical examination. The neurologist needed skill,
knowledge, careful powers of observation, and two simple
pieces of equipment: a safety pin and a reflex hammer.
Sometimes the hammer came with an integral pin, and a
brush for further testing of sensation.
The hammer emerged just as the specialty of neurology
became visible. Historians have puzzled about the relation
between equipment and the development of medical
and surgical specialties. Could cardiology exist without
the stethoscope and ECG or ophthalmology without the
ophthalmoscope? Certainly the reflex hammer coincided
and exploited the new knowledge of the functions of the
nervous system in health and disease that became available
from the middle decades of the 19th century.
Neurological reflexes had long been observed, and 18th-
century doctors put a premium on the nervous system
in the context of disease. “Spasm” has an important,
unappreciated role in medical diagnosis. The elucidation
of the sensory and motor functions of the spinal nerve
roots, by physiologist François Magendie in Paris and
surgeon-anatomist Charles Bell in London, provided
a fertile model for the physician and experimentalist
Marshall Hall (1790–1857). Hall and others established the
importance of the reflex arc (what Sir Charles Sherrington
later dubbed “The way in and the way out”) and doctors
soon noted that various diseases and conditions rendered
them either overactive or less so, and so began their
systematic testing.
A vigorous chop with the side of the hand could serve,
but a reflex hammer was easier. The hammer itself was
derived from the percussion hammer, a product of the
more systematic examination that followed from the
pioneering efforts of mostly French doctors in Paris during
the early 19th century. Germans Wilhelm Heinrich Erb
(1840–1921) and Carl Westphal (1833–90) introduced
the testing of reflexes into medicine in 1875, before the
American neurologist John Madison Taylor (1855–1931)
introduced a specific tomahawk-shaped reflex hammer in
1888. New modifications, with differing materials, weight,
and shape, followed regularly. Unsurprisingly, given the
importance for British neurology of the National Hospital
for Neurology and Neurosurgery, located in Queen Square,
London, there was a Queen Square Hammer, developed in
the 1920s by Miss Wintle, a nurse at the hospital.
The hammer shown here was used at the National Hospital
in Queen Square, but it is a Déjerine hammer, named after
the distinguished French neurologist. It belonged to the
www.thelancet.com Vol 390 August 12, 2017 641
Queen Square neurologist Sir Gordon Holmes (1876–1965) For more on Object lessons
and was part of his medical briefcase that is now preserved see Comment Lancet 2015;
386: 939 and Perspectives
in the UCL Institute of Neurology, closely associated with the Lancet 2017; 389: 2185
National Hospital. Holmes was a noted clinical teacher and
would have used a hammer to diagnose and demonstrate
the subtleties of tendon reflexes to students.
The hammer is most associated with the patellar
reflex (knee jerk), although a complete neurological
examination tests many other reflexes. The knee jerk
is unusual, being effected by a single pair of axons, the
motor and sensory. It was central to the research on the
integrative action of the nervous system done by one
of the greatest neurophysiologists of the 20th century,
Sir Charles Sherrington (1857–1952). Before the outbreak
of World War 1, Holmes’s patients at Queen Square had
provided some opportunities for his clinical investigations of
the role of the cerebellum, referred to by Sherrington as “the
head ganglion of the proprioceptive system”. While caring
for soldiers with head wounds behind the front lines in
France, Holmes was able to greatly expand his investigations
of the complexity of cerebellar function, the design of the
steel helmet leaving this area of the head unprotected. His
thorough range of neurological investigations included
assessments of tendon reflexes. Holmes used a revolving
drum to study and graphically record the aberrant knee-jerks
(and other tests of neurological function), publishing these
findings in a paper in Brain in December, 1917.
The hammer is a simple tool, a seemingly blunt instru­
ment, but it can reveal subtle changes, the interpretations
of which are based on profound research.
*Bill Bynum, Helen Bynum
w.bynum@ucl.ac.uk
Image courtesy of the Queen Square Archives
Gordon Holmes’s much used Déjerine reflex hammer