• Religion and medicine
• medicine in art
• breast neoplasms
• mastectomy
• art and medicine
• history of medical
• cancer care

In 1938, the French Surrealist poet André Breton visited Frida Kahlo and Diego Rivera in Mexico, and acquired, among other objects, the late 18th century painting known as the Peres Maldonado ex-voto for his personal collection (figure 1). For Kahlo and Rivera, the canvas embodied both an indigenous cultural tradition, examples of which they avidly collected and displayed in their home, the Casa Azul, and, especially for Kahlo, a powerful artistic influence.1 2 For Breton, the canvas served as a prime example of the power of folk art to, as he wrote in a 1939 essay, “hold open an inexhaustible register of sensations from the most benign to the most insidious”. That essay, Souvenir du Mexique, featured, along with images by Mexican photographer Manuel Alvaro Bravo, a half-page illustration of the Peres Maldonado ex-voto.3

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Figure 1

Peres Maldonado ex-voto, oil on canvas, 1777 (courtesy Davis Museum and Cultural Center, Wellesley College, Wellesley, Massachusetts, USA).

But that 18th century canvas had originally been created for a purpose very different from 20th century concerns. It is a remarkable example of an early Mexican ex-voto painting, made for display in a Catholic church to express the patron's gratitude for divine assistance in the face of personal difficulty. In 19th century Mexico, these vivid depictions of the trials of daily life, often recovery from serious illness, injury or accident, began to be commissioned in great numbers by rich and poor alike, and they continue to be made for all classes of people today. In the 18th century, when this ex-voto was painted, however, they were expensive items out of the reach of all but the wealthy.4–7

Most early Mexican ex-voto paintings are organised in three zones, often arranged in horizontal bands: a heavenly sphere generally marked by clouds or a nimbus, in which the saint or deity to which the patron's thanks are owed appears; a terrestrial zone where the patron's trials and miraculous recovery are depicted; and a lower register bearing a textual description of the event. The Peres Maldonado ex-voto lacks any explicitly celestial sphere, showing a single domestic interior in the top three-quarters of the canvas. On the left, before an eight-panel folding screen, we see Doña Josefa Peres Maldonado undergoing a mastectomy on her ornate bed, surrounded by female attendants, monks, a surgeon and his assistant. On the right, we see a house altar with no less than seven painted or sculpted cult images; three more pictures of holy figures appear on the red wall behind the altar and in the space above the doorway, the transitional space between the two sides of the painting. Throughout the scene, the gifted though now anonymous artist has carefully depicted the vibrantly coloured textiles, woven or embroidered with rich floral and geometric patterns, that cover the altar and the ground in front of it, the headboard, sheets and pillow of the bed, and make up the surgeon's jacket and the skirts of the attending women. Instead of the emphatic tripartite composition of most early Mexican ex-votos, this one balances an image of the ailing patroness amid her human familial, religious and medical supporters with the depiction of a home altar teeming with multiple and varied sources of divine aid. There is no celestial or visionary zone indicated either by clouds or a golden mandorla or by placement high in the pictorial field. Rather the surgical scene on the left and the house altar on the right are both split apart and joined by the open door, symbol of passage from here to the beyond.

The inscription is even more unusual.

Doña Josefa Peres Maldonado offers this monument of her gratitude to the Most Holy Christ of the Oak [“Santissimo Christo de el Encino”], venerated in his church of Triana, and to the Most Holy Virgin Mary of El Pueblo [“Santissima Virgen María de el Pueblo”], in perpetual memory of the benefit, resulting from her piety, of the operation that was done to her on the 25th of April 1777 when the surgeon Don Pedro Maillé cut from her breast six cancerous tumours, in the presences of the gentlemen and ladies depicted on this canvas.

Unlike most ex-votos, this painting thus has a double dedication. The first is to the Christ of the Oak, which had been found when an oak tree was cut open, revealing an image of Christ crucified; it is depicted standing in the centre of the home altar in the Peres Maldonado ex-voto. Construction of the church of El Señor del Encino (The Lord of the Oak) was begun in the Triana neighbourhood of the central Mexican city of Aguascalientes in 1773, only 4 years before Doña Josefa's mastectomy took place. The second dedication is to the Virgin Mary of El Pueblo, and refers to the Marian icon of the church of Jesús María in the nearby Pueblo de Jesús María (now part of the urban sprawl of Aguascalientes), a town that had been founded in 1701 by displaced natives with the permission of the mayor of Aguascalientes, Diego de Parga y Gayoso. The large figure in white of Mary holding a red-clad Jesus, which approaches the scale of Josefa's youngest female attendant who stands closest to the altar, likely represents this ‘Most Holy Virgin of El Pueblo’. The church of Jesús María had already been completed in 1750, so perhaps the ex-voto's double dedication was made because the church of Christ of the Oak in Triana was still being constructed in 1777, and would not be finished until 1796.8 9

Shown on the home altar, at the foot of the crucified Christ of the Oak, is a sculpted image of the Virgin of San Juan de los Lagos, recognisable by her conical blue mantle, lacy white collar and crown. The cult image in the church of Our Lady of San Juan de los Lagos, some 40 miles south of Aguascalientes, was made with a pre-Spanish medium known as ‘tatzinqueni’, a mixture of corn pith and glue from the bulbs of a local orchid.7 This important local figuration of Mary, to which many ex-votos are dedicated even today, is also pictured in Josefa Peres Maldonado's room twice more, once in a rectangular frame at the upper right corner of the ex-voto, and again in an oval frame over the doorway at the centre of the picture. Also depicted on the home altar are a sculpted image of St Joseph, Dona Josefa's name saint, holding his flowering staff and carrying Christ on a blue pedestal,10 11 a small standing figure of St Anthony of Padua in a brown Franciscan robe, holding the Christ child, and two smaller holy images, one a seated figurine in a high-backed cathedra, and the other a half-length image in an ornate frame. A two-dimensional image of a white-bearded Jesuit in a black biretta, possibly Ignatius of Loyola, Francis Xavier,12 Aloysius Gonzaga13 or a conflation of these saints (personal communication, anonymous external reviewer for Medical Humanities, 2010), hangs over the open doorway, a decade after the order's expulsion from Mexico.14

Whereas almost all early Mexican ex-votos depict some person or persons in an act of devotion towards a religious figure or image, in this one the sacred images on the altar are all but ignored by people gathered on the left side of the canvas. Indeed all the images on or near the altar, except the symmetrical Christ of the Oak and Mary of San Juan de los Lagos, are depicted looking or gesturing towards Doña Josefa as she undergoes the mastectomy, and seem almost to be attending to her rather than vice versa. Furthermore, standing at the centre of the altar, the Christ of the Oak recalls a promise of redemption, a crucifix, found when a sturdy oak tree was cut open. That image of Christ suffering, first on the Cross and again in the splitting of the oak, is placed among four images of Mary (the Virgin of El Pueblo and three of the Virgin of San Juan de los Lagos) and five holy men (St Joseph, St Anthony of Padua, the Jesuit, the dark-robed seated figure and the smallest, framed image at the foot of the crucifix). Across the painting, Doña Josefa lies amid four female attendants and five male ones. Thus Doña Josefa is shown supported by nine members of her earthly community on the left side of her ex-voto, just as the Christo de el Encino to whom the ex-voto was dedicated and whose church in Triana was in 1777 as yet incomplete, is supported by nine images of sacred beings on the right.

Little is known about Doña Josefa herself, or about her surgeon, Don Pedro Maillé, although there is a centuries-long history of breast cancer cases and treatment. As one of the few cancers that could be detected by external observation, breast cancer had long been recognised as a pathological entity. The Edwin Smith papyrus, dating from the period 1500–3000 BC in Egypt, describes cases of breast pathology including tumours and other conditions such as abscesses. Infectious complications were to be vigorously treated “with the fire-drill”. If, on the other hand, the tumours were cool to the touch, ungranulated, without fluid and “bulging to thy hand”, then the verdict was plain: “There is no treatment”.15

Distinction was drawn early between cases of early-stage, localised breast cancer, which could be successfully treated, and more advanced stages for which it was widely recognised that surgical interventions were ineffective. For more than a millennium, the dominant position was that of the 2nd century Greek physician Galen, whose humoural theory argued that breast cancer resulted from coagulation of black bile. Thus, in addition to techniques for amputation of the affected breast, venesection, leeches and other cathartic treatments to purge the patient of melancholic humours were widely applied. By the late Renaissance, Galen's teachings began to give way gradually to approaches based on a new understanding of anatomy and physiology. The anatomist Andreas Vesalius (1514–1564) advocated wide surgical excision of breast tumours and ligation of the arteries to control bleeding. The French surgeon Ambroise Paré (1510–1590) described the spread of breast cancer to axillary lymph nodes. The late 17th and early 18th century witnessed many descriptions of improved surgical techniques aimed at minimising discomfort to the patient and maximising the chances of cure.16 17

By 1777, Pedro Maillé could draw on techniques being developed to improve Josefa Peres Maldonado's comfort and cosmesis, and promote complete removal of the tumours. An account published just 7 years later, in 1784, by Henry Fearon, Surgeon to the Surrey Dispensary, is striking in its parallels to the procedure depicted in the Peres Maldonado ex-voto:

The patient being placed… in a reclining position, her head supported with a pillow, by an assistant behind…; the Surgeon is to place himself… as he finds most convenient, so as to make one horizontal incision, longer than the diseased mass, nearly in the direction of the rib, and a little below the nipple, that it may occasion less deformity. An incision of sufficient extent, being momentary, will give little more pain than a small one; and has this great advantage, that it enables the operator, with facility, perfectly to remove the whole of the diseased parts.

The most painful part of the operation being over, the assistants… are now to hold asunder the teguments, and press their fingers on any arteries that bleed freely, which will enable the Surgeon, with facility and dexterity, to remove the whole of the diseased mass, which should be carefully dissected from the skin above, and below from the pectoral muscles and ribs. The assistants are now to remove their fingers, the blood is to be effectually cleared away, by sponge and warm water, that the Surgeon may examine, with the greatest accuracy, the surface of the wound; and if any small indurated glands, or thickened cellular membrane can be discovered, they ought to be all removed; for without the most careful attention to this part of the operation, the design of it may be entirely frustrated.18

There are differences between Fearon's text and the ex-voto. The mastectomy depicted in the painting is less technically sophisticated than the one Fearon describes, using an incision superior to the breast and removing the skin along with tumour and breast tissue. Nonetheless, the reclining patient, supported from behind; the long horizontal incision being made by the surgeon; the assistant with hand outstretched, about to staunch the flow of blood; the sponge on his tray and cloth in the hand of the monk behind him, ready to wipe away the blood, all give visual form to Fearon's text.

We do not know whether the ‘six tumours’ to which the inscription refers were primary tumours or perhaps axillary node metastases. Regardless, the patient's prognosis was poor, and despite the intervention depicted in this image, Doña Josefa did not long survive. The postscript squeezed between the ultimate line of the original inscription and its scalloped border states:“Although the wound closed perfectly on the 25th of July 1777, other accidents befell her from which she died on Friday, the 5th of September, at 15:00, with clear signs of the patronage of the Holy Image and of her salvation.”