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Pioneers of hand surgery

Erik Moberg (1905–1993)

Erik Moberg was, to say the least, a unique person and a oneof a kind personality with a multifold of skills. Hiscontributions in the field of hand surgery are well documentedand well known. Less known are maybe his other skills thatrange from archeology and ancient cultures to being a devotedsailor and collector of butterflies. His never-ending curiosityand willingness to learn and relearn in the broadest aspect of lifeare assets that need to be emphasized and hopefully followed byyounger colleagues. Erik was a true academic and a role modelfor people striving for perfection regardless of topic. He joineddiscussions, often with strong opinions, but with a good moodand open mind. He delivered numerous memorable lectures thatalways took the audience further than expected by provokingthe listener to become active and thoughtful. He was not afraidof challenging the so-called state -of –the-art and he keptstressing that state -of –the-art is a dynamic process that we areall involved in. In other words, the interaction between expertson a regular basis was fundamental for development. In thisintensive process of communication, Erik stressed the need forcollecting information not only from experts but also frompatients and laymen because they may present, directly orindirectly, the key to a major scientific break-through.

If one picked a special topic that magnetized Erik Mobergit would no doubt be phenomenon and significance of skinsensation. In his clinical accomplishments sensation certainlyplayed an instrumental role. The following citation representsErik’s interest bordering obsession of sensation as well as hisfirm opinions about how to assess sensation. Or maybe morecorrectly what techniques not to use for evaluating sensation:‘‘It must be emphasized that sensibility is, in my opinion andaccording to my experience, the basis for reconstructivework. . . for reconstructive surgery, ‘‘feeling’’ is a totallyuseless term, as it covers far too much and distinguisheshardly anything. . . for examination of useful sensibility inreconstructive hand surgery of all the tests evaluated by theauthors, the only one which was found to be significant is thetwo-point discrimination test now performed with a paperclip.All other tests of sensory function, in my opinion, should inthis work be abandoned, including cotton wool and paperstrip, pinprick, ordinary tuning fork, the difference betweensharp and blunt, figure writing, the wrinkling skin test and thetwo-point discrimination test performed with sharp pointed

compass. They are not only useless, they are evenmisleading’’ [7].

Erik Moberg graduated from the Faculty of Medicine,University of Lund in 1932 and his first appointment as a doctorwas in Persia (1932–33) where he met a Swedish nurse, Märta,whom he married in 1934. He defended a thesis in experimentalpathology at University of Lund 1936 and began training inorthopaedic surgery, moved to Göteborg and the Department ofSurgery at Sahlgrenska Hospital where -in 1942- he became asenior staff member.

In 1944, he began to treat hand injuries inspired byDr Bunnell’s principles (Surgery of the Hand, 1944). Heorganized a separate ward for treatment of fractures due to theirwound infections and abscesses. In 1949 he had the first handsurgery ward in Scandinavia fully organized and established atthe Sahlgrenska Hospital.

In 1947, Erik spent several months with Dr Sterling Bunnellin the U.S where he observed the post-war treatments at handsurgical centers. Back in Sweden he started the first handsurgical ward in Scandinavia in Göteborg.

Erik was always very interested in teaching and especiallyhis new concept of treating hand injuries. He wrote a bookEmergency Surgery of the Hand in 1948, which has beentranslated into many languages and published in severaleditions over the years. Erik Moberg introduced hand surgeryofficially in Sweden in 1948.

In 1951, he formed the Nordic Hand Club (now theScandinavian Society for Surgery of the Hand, SSSH). He wasinspired by the American Society for Surgery of the Handwhich was started by Bunnell in 1946. In the early 1970´s the‘‘Moberg lecture’’ was founded at these meetings. In 1956, ErikMoberg was given a personal professorship in ExtremitySurgery and in 1958 in Hand Surgery. Erik trained severalsurgeons, and five of them became full time hand surgeons andthemselves established centers in different parts of Sweden.

In 1958, Erik attended a meeting of the Second Hand Cluband became one of the first Corresponding Members. This clubeven toured in Scandinavia and was accompanied by manyothers from Europe and the USA in 1961. This was the firstinternational meeting and was organized by Erik. This was alsothe foundation for meetings with a high level of scientificpapers. Arthur Barsky, President of the American Society, was

Chirurgie de la main 29 (2010) 145–146

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approached and many international meetings in Edinburgh,Turin, Rio de Janeiro led to the beginning of the InternationalFederation.

In 1962, he presented the first annual Sterling BunnellLecture to the American Society for Surgery of the Hand. Thetitle of the lecture was ‘‘Aspects of sensation in reconstructivesurgery of the upper extremity’’. Erik Moberg made severalimportant scientific contributions in the field of hand surgery.He was especially interested in sensibility and he introduced theterm ‘‘academic sensation’’ or tactile-gnosis type of sensi-motor feed-back driven performance-related sensation (‘‘whata hand can do’’) as opposed to functional or discriminatorysensation [1,2]. He devised methods of ‘‘transferring sensa-tion’’ by moving island flaps from a less important area tocontact surface for grips [3]. He also spoke of earlysynovectomy for the small joints in rheumatoid disease.

In 1968, Erik was elected as the very first president of theInternational Federation of Societies for Surgery of the Hand,IFSSH. In 1969 Sweden became the first country in the world tohave hand surgery recognized as a separate specialty. Moberg

did not want hand surgery to be a specialty on its own, but ratheras ‘‘extremity surgery’’ which would cover upper and lowerextremities, spine and pelvis. The creation of the firstspecialized hand surgery units and even more so the recognitionof the hand surgery specialty were directly against the desireddevelopment of Erik Moberg. He was, however, flexible andonce a fact, he played a major role to evolve and refine the handsurgery profession.

In 1971, after his retirement Erik started working on thesurgical rehabilitation of patients with tetraplegia [4]. Hecontinued this work during the remaining years of his life. Hisextensive monography on tetraplegia surgery from 1978 istoday considered a bible [5]. His last article on this subject waspublished in 1992. Moberg has said ‘‘after hearing Bunnellspeak, I have never been able to leave the question of sensibilityin hand function’’. He applied much of his knowledge aboutsensation to classification and treatment strategies in tetra-plegia. Erik Moberg had earlier introduced the Ninhydrin test todocument objectively innervation. He defined hand function asprecision-sensory and gross-sensory grips. He correlated Webertwo-point discrimination with hand function. He introduced thepick-up test to document hand function. He coined the term‘‘tactile gnosis’’. He hypothesized that proprioception isprincipally due to skin- not joint- afferents and he classifiedthe tetraplegic hand according to its combined sensory andmotor capacity.

Above-mentioned examples just represent a selection of themulti-fold of remarkable achievements [6,7] and wonderfulmemories that Erik Moberg generously distributed to theacademic, clinical and social world (Figs. 1 and 2). The first,second and probably even later generations of hand surgeons inSweden and many other countries certainly consider ErikMoberg a role model and leading star in their careers.

References

[1] Moberg E. Objective methods for determining the functional value ofsensibility in the hand. J Bone Joint Surg (Br) 1958;40(3):454–76.

[2] Moberg E. Objective method of evaluating hand sensation and its use inreconstructive surgery. J Bone Joint Surg (Am) 1959;41(4):777.

[3] Moberg E. Technical aspects of the transfer of neurovascular flaps. J BoneJoint Surg (Br) 1964;46:359.

[4] Moberg E. Reconstructive hand surgery in tetraplegia Stroke and cerebralpalsy: some basic concepts in physiology and neurology. J Hand Surg (Am)1976;I(I):29–34.

[5] Moberg E. The upper limb in tetraplegia: a new approach to surgicalrehabilitation. Stuttgart: Georg Thieme Verlag; 1978.

[6] Hagert CG. Erik Moberg 1905–1993. Acta Orthop Scand 1993;64(6):717–

24.[7] Dellon AL. The sensational contributions of Erik Moberg. J Hand Surg (Br)

1990;15B:14–24.

J. Friden*

M. Knall

Department of Hand Surgery, Sahlgrenska University Hospital,SE-413 45 Göteborg, Sweden

*Corresponding author

E-mail address: jan.friden@orthop.gu.se

Fig. 2. Professor Moberg congratulating Dr. Esther May at her Ph.D. disserta-tion in 1992.Photo Dr. Ann Nachemson.

Fig. 1. Professor Moberg in his beloved sailboat. Many of Erik Moberg’sinternational guests participated in and enjoyed shorter or longer sail trips alongthe Swedish west coast.

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