Background

We all know nautical art – those tiny little ships in bottles, made by sailors whiling away the long winter months; and peasant art – those carved wooden tools that are the pride of folk museums everywhere. Are we now seeing the advent of a new art form – surgical art?

PMMA, an acrylic cement, was introduced into dentistry in 1933; today, 150,000 kits are used annually in France. This development has gone hand in hand with the evolution of a new art form that has been confined to operating theatres: polymethylmethacrylate sculpture – with or without added antibiotics.

 

The raw material – PMMA

Antibiotics – at least the aminoglycosides gentamicin or tobramycin – have something to do with fungi.

So, if we have fungi in the sculptors’ raw material, would that be like the eggs used by early Italian fresco painters for mixing their tempera colours?

The culinary association is surely coincidental: the artist may choose whether he or she uses PMMA with or without antibiotics, but that choice is guided by considerations that have less to do with aesthetics and everything to do with treating patients. It’s not a question of how but of where the sculpture is being made.

It is true that the addition of antibiotic may tint the PMMA a novel and particularly attractive hue; however, that will be purely by chance, as a result of a one-off mixture that is just that little bit different.

As a rule, PMMA sculptors have a restricted palette at their disposal, and the colour obtained will show where the raw material came from: shades of green mean a PMMA made in Germany; white, a cement of American or Swiss provenance. Often, the effect is heightened by a red which, prior to polymerization, could be described as ‘blood’, but which has a tiresome habit of turning to ‘black pudding’ when the proteins have coagulated as a result of the heat evolved as the cement is curing. However, there are some rich iodine browns, which bear witness to irrigation with a tertiary amine whose colour is not affected by heat.

The production of the raw material (a mixture of a fine, usually white, powder, and a liquid) is not unlike that of levkas (from the Greek leukos = white), a mixture of plaster of Paris powder and glue, which was used as a ground for most of the old Russian icons.

The polymer-monomer mixture lends itself to the creation of “original” works of art, the only tool required to work this naturally plastic material being the artist’s hands. Just as with clay, which has been in use since times immemorial, shapes may be created by taking bits away from the original lump, or by adding some more material (dumplings or sausages), sometimes with the use of instruments.

PMMA is an invention of our times, which has literally given rise to surgical art, although it has also been known to come in handy on the domestic scene. Discretion forbids me to reveal the name of the surgeon who, many years ago, relieved me of a kit of green cement, to repair the buggy of his toddler (who must be in his twenties by now). Having seen how well it worked, I used the material myself to put together for all times a screw-dowel-wall composite destined to support the door of a cubicle. However, this is straying from the realm of the artist into that of the artisan – although, in the art that we are dealing with here, the line between the two realms is a tenuous one: sculpting is reckoned to be a subform of tool-making; and while the examples of PMMA sculpture shown here are mainly proper little figurines, theatre nurses have been known to use bone cement to make handles for pins and K-wires.

 

Features of PMMA sculptures

PMMA sculpture is essentially small-scale (using up what is left over from a 40-g polymer/20-mL monomer kit); thus, the works of art are moveable and portable, and can easily be taken from the production site (the operating theatre) to an exhibition site (such as a common room, the surgeon’s consulting room, or matron’s office), where they usually form a “collection”. There is a more advanced form of collection, known as a “group”, in which the separate little figures are united by a common theme: I was given access to, and allowed to take pictures of, the Nativity at Raymond Poincarré Hospital in Garches.

Sadly, when operating departments move into new premises, these examples of naive art often lose houseroom; in many cases, entire collections (such as the animals at Cochin Hospital, or the pin handles at the Tripode in Bordeaux) have been considered a waste of space, and thrown on the skip.

When they do not fall victim to removals, PMMA sculptures are durable, since the material from which they are made is very strong. This will protect them from the fate potentially suffered by sculptures made from terracotta or similar materials. (Don’t ever expose a terracotta figurine to a pressure of 100 MPa just because your PMMA sculptures would have no problem standing this load.)

Also, unlike wood carvings, PMMA will not rot, and will not be attacked by woodworm.

However, a PMMA sculpture may be short-lived if its creator decides that it should be so. In many cases, the object does not last beyond the curing time, and serves merely as the indicator of cement hardening that it was originally intended to be. Once this purpose has been served, it is thrown away like all the other surgical waste – bits of sutures, used needles, swabs, etc.

As with other newly introduced materials, one may also wonder whether the use of PMMA has opened up new horizons of artistic activity. After all, the advent of glass, steel, and concrete resulted in the disappearance of long, low buildings made of brick and timber, and the emergence of tall, slender urban high-rise structures. The specimens kindly provided for my examination suggest that the statuary made of bone cement is fairly similar to the clay items produced by prehistoric artists or the play-dough sculptures made by 7–8-year-olds.

Does that, then, mean that 21st-century surgeons draw their inspiration from the same sources as Cro-Magnon man? Or that there is needs a slumbering Rodin in every theatre nurse that kneads a lump of cement?

These are the questions the present study was designed to answer.

 

Contemporary PMMA works of art

The works of art shown here are genuine, in that they were created spontaneously, rather than “commissioned” for this article. I am grateful to all who loaned specimens from their personal collections, and wish to apologize to all whose rubbish was rummaged through to find some more. The items are discussed in five main thematic categories.

1- Animals

Our zoo is made up of a large dinosaur, two reptiles, ten mammals (wild as well as domestic ones), and three birds.

Perhaps it is because of a distant memory of humans being hunter-gatherers (before settling down to farm) that animals and plants occur so frequently in the output of artists and of artisans.

In the Dinosaur and Reptile category, a budding Praxiteles has produced a splendid stegosaurus (Fig. 1), who must have come from the collective unconscious, albeit an unconscious shaped by films on the telly, since these beasts roamed the earth in the Mesozoic era.

 

The first reptile is a snake (Fig. 2), with a bump on the head that makes it look very much like the boa constrictor in Antoine de Saint-Exupéry’s Little Prince. I read the story when I was a child, and have ever since been able to tell a boa that had swallowed an elephant from a hat. (Fig. 3 shows the boa from the outside and the boa from the inside, just in case readers have forgotten the story). This made me wonder immediately what this particular boa constrictor might have swallowed.

I seemed to remember that this snake was also involved in the nativity at the Raymond Poincarré; his presence in a religious tableau suggests that what it had swallowed was, in fact, that famous apple that got our earliest ancestors into trouble in the garden of Eden. And why not – artists have always been notorious for the anachronisms in their work.

The second reptile is a chunky little tortoise (Fig. 4). I wonder whether it owed its creation to the fact that it is reputed to be slow - as slow, in fact, as that cement that takes exasperating ages to cure.

Similarly, in the Bird category, that beautifully expressive little owl (Fig. 5) may have been born of the artist’s frustration with an over-long shift at the hospital.

The hen and her chick (Fig. 6) could have come straight out of last year’s sugar Easter egg.

The ten mammals belong to a group called a Nativity; they are put up every year with the Christmas decorations on the ward.

There are several interesting things about these animals:

The collection is open-ended (other animals could be added to it).

The figures are stand-alone, but interact with each other.

The little sculptures have been given a surface texture and painted with coloured crayons; in some cases, plaster has been added to the PMMA.

The stock comprises a saddled equine, obviously ready to depart (Fig. 7). Since this is a Nativity, it would make sense to see it as a donkey; in fact, it could be the donkey that was shortly to go with the Holy Family on their flight into Egypt. There is an ox (Fig. 8) that has lost its right ear and hind leg, undoubtedly when something went wrong at the curing stage; a pink-nosed, blue-eyed sheep (Fig. 9) that does not look particularly lost, since it has got its shepherd by its side; a cat with a collar and blue eyes (Fig. 10); a goat (Fig. 11); a tiger with blue stripes (Fig. 12); a hippopotamus made of green PMMA with a surface coat of plaster of Paris (Fig. 13); a plaster feline with its paws tucked under (Fig. 14); and a very expressive quadruped whose round eyes and square muzzle suggest that it may be a baby calf (Fig. 15).

As may be seen from the above remarks, it is not always easy to tell what exactly these creatures are supposed to be. But, then, life-like representation is obviously not what these PMMA figurines were intended to provide. There must thus have been other reasons for their creation.

 

2- Humans

There are, in all, five human figures:

Mary and Joseph, who have also been “enhanced”, dressed, and “accessorized” (Fig. 16).

There is the above-mentioned shepherd, wrapped in his brown cloak (Fig. 17); a moustachioed snowman with a buttoned waistcoat (Fig. 18); and a chap in standout 3D (Fig. 19), with a phallus measuring two-thirds of his height, enough to provide him with a “middle leg” in more ways than one.

3- Decorative objects, including jewellery

Someone with delusions of grandeur has made himself a huge and lavishly decorated sealing ring (Fig. 20); a surgeon with an eye for the ladies has fashioned an ear ring for his scrub nurse – an ear ring for Alexandra (Fig. 21); while a third joker has made himself a splint for resting his weary finger when the time comes (Fig. 22).

At the Poincarré, someone had the idea of making a cat bowl (which could equally be interpreted as the manger that baby Jesus lay in) (Fig. 23); while another member of the theatre staff created a rudimentary wheel (Fig. 24) which, to the hungry, may look like a goat cheese.

 

4- Plants

A newcomer at Stryker was attending an introductory course to familiarize himself with the behaviour of bone cement; he spontaneously created a mushroom from the leftovers of his classroom work. His teacher (the author of this article) has not yet managed to identify the fungus; neither does she know what prompted its creation.

Had there been too much talk of ascomycetes? (We had had quite a long session on tobramycin) – but, then, this specimen is distressingly white (Fig. 25), and quite unlike what one would associate with an Aspergillus that rightly bears the epithet niger.

So, would it be a magic mushroom that gives one hallucinations? In which case, the message might have been that the lecturer was out of her mind.

Or a poisonous toadstool? In which case, the message would have been clearer yet, and the object might have been intended for the same sinister purpose as those dolls that have pins stuck into them.

5- The male member

This seems to be the most frequent image to rise from the collective unconscious of the surgical profession, and there is a substantial body of willies, dicks, and peters in PMMA (Figs. 19 and 26).

Perhaps the earlier technique of finger-packing cement down the medullary cavity has something to do with the surgeons’ phallic fantasies. There again, an object is either solid or hollow; and to psychoanalysts, especially those of the Freudian persuasion, either shape would have a sexual connotation.

Religion, humans, animals, plants, sex, and ornament – all human art is there. The medium may be different, but the ideas expressed trace all the way back to prehistoric times.

 

Fast art

PMMA sculpture may not be lightning art, but could, perhaps, be described as “fast art”.

Those who work with clay, with wood, or with stone have a freedom that users of bone cement do not enjoy: time is not on the side of the PMMA sculptor. If the clay item hasn’t quite got the curve the artist had in mind, no problem: wet the material again, and retouch it to get the desired shape. If the marble sculpture isn’t coming along as planned, put down the chisel and mallet, leave the work, and start again next day. With PMMA, no such luck.

The solid-phase (PMMA) molecules and the liquid phase (MMA) molecules bind together in an irreversible process that happens in a comparatively short space of time (around ten minutes), and takes place in an unalterable sequence of steps. There are barely a few minutes between the “working time” and the “setting time” of the cement – and that may not be enough for perfecting the work of art. A rush of creative activity and perfect technique are required in order to fit the sculpting into the limited time available.

Even so, huge numbers of figurines lose bits later on, as a result of laminations in the cement.

Thus, unlike works of art in other media, PMMA sculpture is fast art – quickly made, and, sometimes, quickly unmade.

It is also noticeable that surgeons and theatre nurses tend to play down the value of their creations in PMMA, and do not consider the making of these little figurines as an art form.

 

Made specially for you

When asked why they make these sculptures, some surgeons will say that the release of tension after an operation is conducive to creation. To them, handling a left-over bit of curing bone cement means that the implant has been inserted and the procedure is virtually over. Everybody in the theatre heaves a sigh of relief; and if the surgeon feels that he has done a reasonably good job, he will experience an almost subconscious sense of joy, a childlike glee that manifests itself in handling and playing with the cement. It is almost a discharge of motor energy, the same as can be seen in children allowed to handle any substance that can leave a mark, be it spilt porridge or a lipstick left half uncapped. One surgeon actually refers to the process as “leaving a mark” – an urge which child psychiatrists recognize as one of the mainsprings of human behaviour.

Other surgeons, however, find the time spent waiting for the cement to cure extremely stressful. They worry and fret whether it will set properly. Obviously, things can go wrong unexpectedly; storage and mixing conditions, and one-off factors, may upset the wayward material.

In such situations, making something out of cement is a ready means of relieving one’s anxiety and overcoming the sense of lack of control over what is happening. Perhaps cementless arthroplasty was devised because it does away with this mental stress.

Sometimes, the sculpture is unplanned: the artist-to-be starts out playing with the material, and things literally take shape by and by.

More often than not, however, there is a thought or an intention behind the object made. Sometimes, the sculpture is intended as a token of affection for a loved one, usually a child. The animal or other object made by the parent and given to the child has a bonding function:

for the creator, at the moment of creation (he or she is making something for, and is thus mentally close to, the child);

and for the recipient, to whom the object is a visible sign that someone cares for them.

The relationship thus established may be played out time and time again. The child may “commission” another animal to round off the collection, or a cot or basket for the animal received on a previous occasion, etc.

There is universal agreement that the success of the sculpting process will depend upon the sculptor’s mood, fatigue, and mental condition at the time of shaping the material.

It follows that surgeons and theatre nurses who play with PMMA are not so many Rodins; they are not powerful realistic sculptors producing works of art of enormous expressivity. They are people whose job it is to “fix” broken bodies; and in sculpting objects, they express their fears, their fatigue, and their delight in an activity that is, in equal measure, playful, simple, and liberating.

The end result may be a work of art or some rough-crafted object. The important thing is that the sculpture expresses the unity of the human being and the world he or she lives and works in; of matter and the spirit that shapes this matter; of the subject and the object; of that which is created and him or her who creates it.

It also establishes a bond with the person for whom it has been created.

Ladies and gentlemen of the scalpel: Once your art will have become more widely appreciated, do not be surprised if, one day, one of your little patients will look at you in the induction room, and, just before being put to sleep, will plead, like the little prince in the story, “If you please, make me a sheep.”