Medical Masculinity and the Sensation of Suffering in Leonard Portal Mark’s Acromegaly (1912)

In 1912 physician Leonard Mark published a book titled Acromegaly: A Personal Experience . Within, he documented his life suffering from the titular condition which manifested in symptoms ranging from headaches to the hypertrophic enlargement of the head, hands and feet. As the condition began to affect Mark’s ability to perform his medical and artistic work his writing had to contend with his changing identity, body, and the problem of how to effectively explain the experience of his suffering. At the same time as the wider medical profession was becoming fixated on acromegaly as a disease defined almost wholly by its spectacular visible symptoms, Mark’s writing invited his reader to go beyond the merely visible and engage with his narrative on a multisensory level. What emerges in Acromegaly , and what this paper explores, is how Mark used contemporary ideas of medical masculinity, particularly in deconstructing them, to invite this sensorial engagement.

that "a huge crab is clawing hold" of it.1These restrictive, oppressive, numbing, and violent descriptions were used by physician and artist Leonard Portal Mark (1855-1930) to try to explain an idiopathic experience that plagued him for over half of his life which he termed 'faceache.'Since the age of twenty-four Mark had suffered with an additional variety of symptoms, which included fatigue, headaches, problems with his vision, and the gradual enlargement of his hands, feet, and jaw which no doctor, himself included, could readily explain.It was not until 1905 when a then fifty-year-old Mark realised that the cause of his various symptoms was the condition acromegaly.The disease had first been named in 1885 by French physician Pierre Marie (1853Marie ( -1940) ) who gave it the name acromegaly, from the Greek words for 'large' (megalos) and 'extremities' (akros). 2 In 1912, seven years after his self-diagnosis, Mark published a book titled Acromegaly.A Personal Experience in which he wrote about his life with this new and rare disease.Best described as an autopathography, the book itself is an unusual contribution to the medical writing of the early twentieth century.Doctors have, of course, long made use of self-observation and self-diagnosis in their work and many private accounts have revealed how their own experiences of illness operated within their contemporary medical practices and theories.3Though published doctor-written autopathographies are now somewhat in vogue, they have historically been much rarer.4 Thomas Sydenham (1624-1689) is one of the best-known cases of a physician giving an account of his own illness having published in 1683 a detailed treatise on his sufferings with gout.5 Mark, however, made it clear that he was not writing a medical treatise.What he aimed for in the book was not to extrapolate from his case any Nuncius (2023) 1-27 | 10.1163/18253911-bja10072 types or standards for the disease but to focus instead on the complexities of his individual experience.Acromegaly is made up of autobiography, pathological observations, as well as short reports on his numerous symptoms from fellow medical men.Most of the twelve chapters that make up the book are devoted to single symptoms such as 'noises in the head,' 'lethargy,' 'ocular troubles,' and of course 'faceache.'His prose is scattered with passages recording the minutiae of his day-to-day pains, lists, tables and charts tracking his symptoms, and several kinds of images.These included photographic portraits from his childhood to age fifty-six, charts recording his declining field of vision, four large fold-out pages reproducing x-rays of his hand and skull, an outline diagram of his head, an ink print of his hand, a sketch of one of his chin hairs under a microscope, and a photograph of a thirteenth-century stone statue on the side of Reims Cathedral (of which more later).
This hodgepodge of literary, medical, and visual forms coalesced into a poignant attempt to communicate the experience of suffering from a condition that went from complete unknown to medical obsession over the course of Mark's life.After Pierre Marie's identification of acromegaly, the medical profession quickly came to define it by its striking visual symptoms in the form of the overgrowth of the hands, feet, and lower face.Mark though paid relatively little attention to these.Instead, he used his autopathography to challenge the primacy of the spectacularly over-grown body and to instead communicate the affective intimacies of pain.In Acromegaly, it seems that he wanted readers not to fixate on the strange external changes to his body, but to feel the various pains and sensations that had more insistently shaped his experience of the condition.
He invited this sensorial engagement largely through invocations of touch, and specifically, forms of touch that evoked some transgression of bodily boundaries.Each image and description he included in Acromegaly brims with this haptic potency.Take, for instance, the skiagram of Mark's hand (Fig. 1).It is a double-page size, requiring the reader to unfold and reveal the image with their own hands, inviting a comparison between theirs and Mark's as they do so.The image itself reveals the interior of Mark's enlarged hand, the faint shadow of the fingers outlining the bones reminds the viewer of that once impermeable boundary between inside and out.Mark invited similar tactile engagement in his prose.It is difficult to encounter the descriptions of the cold stream of water or pinching crab that opened this paper without imagining them somehow pushing insistently at the side of your face.My focus in this paper is to explore these invocations of touch and multi-sensorial engagement in Acromegaly.In keeping with the wider theme of this special issue on "Touching Visions," I have turned to the exploratory lens of gender.What I want to suggest here is that Mark played on and with contemporary cultural norms and anxieties around masculinity to evoke the dissolution of boundaries necessary to transport the reader from sight to touch in his account.
At the turn of the twentieth century, much as today, masculinity was a complex and shifting thing.Historians of gender have demonstrated that whilst there were some identifiably distinct fashions of masculinity these were far from hegemonic.6Historians of medicine have added further depth to understandings of medical masculinity by exploring the emotional and embodied identities of practitioners.7 Whilst this article focuses on one somewhat anomalous text, it intervenes in these studies of gender and professional identity, offering a close reading of how gendered ideals and professional masculinities were constructed and deconstructed by Mark as a way to explore and explain his embodied experience.Pain and gender are interlinked concepts Nuncius (2023) 1-27 | 10.1163/18253911-bja10072 here.As Javier Moscoso has written, "[h]alfway between the world of emotions and the realm of sensations, the history of pain refers back to the history of experience."8A focus on Mark's account of his experience allows us to see how pain can both destroy and (re)create ideas of gender, and how gender has been used to reveal and understand the embodied experience of pain.
Somewhat artificially, I have broken down considerations of Mark's masculinity into three areas, which allows for the complexities of both gender and sensory histories to emerge.The first section explores the masculine ideal of the gentleman physician in the early twentieth century, a figure which Mark recognised as kindly, stoic, and civilised.Yet his condition rendered aspirations to this identity as precarious and his account in Acromegaly suggests that civility and gentlemanliness could easily give way to atavism and barbarity in the culturally anxious early century.The second section turns to the spectacle of the acromegalic body and the ways in which Mark sought to make his weakened body useful in order to fulfil the duties of the doctor in advancing medical knowledge.This involved him understanding his embodiment within a realm of material objects rather than as a masculine doctor.In the final section, I look at the idea of observation and the limits of self-observation for the medical man.As a doctor and artist Mark was a keen observer, but neither his diagnostic nor drawing skills had allowed him to determine the cause of his own condition until relatively late in life.Finding himself occupying the boundarythreatening position of patient-physician, Mark invited medical colleagues to give their own observations of his condition, whilst simultaneously revelling in offering minute, often inconsequential details from his own experience.

The Gentleman Physician
Gender has been a key element in the construction of medical identity, and various medical identities have in turn reshaped and inflected masculinities.9This section will explore the way in which Mark's understanding of his professional gendered identity became a way for him to explore the effects of his acromegaly on his own life.A particularly relevant manifestation of masculinity here is usefully termed the 'gentleman physician.'As Christopher Lawrence has shown, this was an identity cultivated by a certain set of late-nineteenth-century doctors clustered in metropolitan centres such as London who distinguished them- selves through stressing the value of a classical education, a generalist approach to medicine, and professional work in the upper echelons of society.10In many obvious ways this was an identity Mark aspired to.Yet, as this section explores, this was also an identity which he strategically constructed and deconstructed in order to explain the experience of acromegaly.
Mark was raised and educated mostly in Marseilles where his father, Edward Walhouse Mark (1817-1895), was a diplomat.At the age of twenty, he left France for England to train as a physician, going on to work in a number of hospitals around London and Surrey before settling in London.Coming from a relatively elite background, Mark did not share the worries of a large proportion of physicians at the time whose medical work allowed them access to a certain degree of cultural esteem but whose more middle-class origins meant they lacked the assured status of the hereditary gentleman.11Indeed, his connections assured him an appointment at St Bartholomew's Hospital alongside his private practice.12A gifted draughtsman, he went on to take up the role of pathological artist at St Bartholomew's Hospital pathology museum in 1887.Here he spent much of his time producing elegant watercolour drawings of patients and pathological specimens to augment the museum's teaching collection.13 Mark regularly travelled in Europe, summering in the South of France with family or accompanying wealthy patients on restorative jaunts to the healthy centres of Europe.In 1906, he was elected president of the West London Medico-Chirurgical Society and, perhaps inspired by the artistic side of his professional life, his presidential address was on the subject of "Art and Medicine."14This address, though it does not mention the acromegaly he self-diagnosed just one year prior, has much light to shed on his conception of medical masculinity and the ways in which his acromegaly challenged this ideal.
One painting which drew Mark's attention was Luke Fildes' (1843-1927) The Doctor, then on display at the Tate Gallery and widely reproduced elsewhere (Fig. 2).The painting, a sentimental depiction of a doctor lost in his concern for Who Banks' 'critics' were is unclear though his words suggest a somewhat embattled attitude indicative of a profession striving for appropriately respectful recognition.Barry Milligan's analysis of The Doctor has shown the political role the painting played in contemporary discourse over professional ideals, focusing on how it projected an idealised vision of doctors' work as characterised by a "heroically selfless professionalism."17Despite Banks' comments suggesting the painting's verisimilitude, it was certainly more of a romanticised fantasy than documentary.Physicians like Mark, with lucrative private practices and distinguished positions in major hospitals would likely rarely, if ever, set foot in the modest homes of the working classes depicted in Fildes' painting.
Yet the rapturous reception of Fildes' painting among doctors reveals much about the ideal qualities of the medical man at the turn of the century.It was inspired by Fildes' own experience of losing his son Philip in 1877 and how struck he had been by the kindness shown by the family doctor.Mark's treatment of the painting showed a great deal of sensitivity to the way the artist depicted this kindness: In this picture morbid details are conspicuous by their absence.The whole interest of the subject, the critical condition of the child, is conveyed to the observer by the distress depicted in the face of the father, by the mother's attitude of despair, and by the kindly look of the doctor, which is expressive of deep concern for the recovery of his little patient.18 This quality of kindness and with it a sort of stoic heroism was also common in other sentimental portrayals of physicians in the early twentieth century, suggestive of an idealised medical masculinity dependent on strength of character in the face of hardship.19Mark too articulated these tacit expectations of the doctor noting on the first page of Acromegaly that writing the account allowed him "to record some of the great kindnesses that I have received from numerous professional friends, who with their skill and sympathy have made my path in life smoother and my burdens lighter."20Skill and sympathy then were acknowledged as important markers of medical masculinity by Mark  his contemporaries.In particular, these were usefully vague features particular to the gentleman physician archetype; who, as Lawrence has shown, was a well-bred, well-educated, upper class figure who represented tradition and a generalist approach to medicine as opposed to newly emerging competing medical ideals such as the specialist or the scientist.21 Mark certainly recognised this skilled, sympathetic hero figure as the ideal gentleman physician, yet his account of his acromegaly often consciously deconstructed these ideals.One recurring symptom he detailed was the overproduction of increasingly uncontrollable tears that threatened the stoic ideal he and others imagined for themselves.He noted how his, at times constant, crying had even eroded the physical markers of his masculinity."If my moustache, an important feature some twenty-five years ago, is now so grizzled and scanty, it is, no doubt, because the tears have come to the aid of time, and, by their constant flow, have soaked and rotted the root of the hairs and caused them to drop out."22Beyond his moustache he also noted the effects on sartorial class and gender signifiers."The tears also play havoc with the flaps of my frock coats.When I am in evening dress my shirt-front suffers, and does not remain long in the immaculate state in which it left the hands of my laundress."23The excessiveness of these cultural markers of emotion were literally rotting away the outward signs of masculinity and staining those of class.
Class concerns were especially evident in the wider work on acromegaly.Mark recalled in later writings his meeting with a woman who, despite bearing all the hallmarks of acromegaly, resisted the diagnosis, as she believed the disease was "only one of low class people, and was only seen and known among quite the poorest."24Mark assured her this was untrue, doubtless using his own case to assuage her worries.However, the association acromegaly developed with the poorest class was likely rooted less in reality and more in contemporary concerns about the classed body and concepts of civilisation.As Western imperial powers struggled and their fears of colonised peoples flourished, a cultural pessimism around the power of the white male body grew in Europe.25 The threat of degeneration was affirmed by science and medicine and the spec-10.1163/18253911-bja10072| Nuncius (2023) 1-27 tre of atavism loomed large in society.Its proxy became a working-class male body ravaged by bad breeding, bad living, or bad working.26Likely it was this figure whom Mark's concerned consultee had in mind when she noted that it was only the 'low class' who could bear the deformities of the acromegalic.One might easily assume that Mark's attitude to this would be to downplay the association between acromegaly and degeneration in order to reassert his status as the idealised gentleman doctor.Instead, this element seems to have given Mark an opportunity to disassemble these gender and class expectations in order to re-insist on sensory experience.
Amongst the many notes and images created by his medical associates that Mark included in Acromegaly was a large foldout diagram of his head in profile drawn from measurements made by anatomist and anthropologist Arthur Keith (1866-1955) a figure known primarily for his work on evolution (Fig. 3).In 1911 Keith, then conservator of the museum of the Royal College of Surgeons, published an article titled "An Inquiry into the Nature of the Skeletal Changes in Acromegaly" which was inspired when he came across an acromegalic skull in the College museum which bore a striking resemblance to the typical Neanderthal skull.27At the time at which Mark solicited his opinion Keith was working on a book that would be titled Ancient Types of Man (1912) and both men were interested in the physical resemblances of the acromegalic to Neanderthal man.Keith's Ancient Types of Man included a section on the function of the pituitary gland which stated that "[w]hen this gland becomes enlarged, as it occasionally does in the disease known as acromegaly, the Neanderthal characters are developed in the subjects of the disease in an exaggerated and bizarre form."28Keith also included numerous diagrams of the varying skull shapes of ancient human remains which took the same visual form as the diagram Keith submitted to Mark.
By the time Mark published his Acromegly in 1912 the theory that some action of the pituitary gland was responsible for acromegaly had gained significant traction.However, there were still other theories around, most of them regarding the possible role of the thyroid gland.One of the markedly less popular theories though disconnected acromegaly from both the pituitary and the thyroid glands entirely, instead positing the disease as an "atavistic perversion of growth."29Keith himself was careful to distance himself from such atavistic theories stating that "I do not for a minute suggest that the Neanderthaloid race suffered from acromegaly, nor that acromegaly is a resurrection of an anthropoid state."30Instead, his interest lay in the action of the pituitary body in producing the characteristic skull shapes of both the Neanderthal and the acromegalic.
Mark though seemed uninterested in the nuances of Keith's work and instead lingered on the figure of the Neanderthal.Overlooking the physicality of the figure he wondered instead about what sort of life the Palaeolithic man must have had."Did he also suffer from headaches?If so, he has my sympathy.I can imagine his and his comrades' joy in their flint implements wherewith to split open each other's skulls.No doubt they thought thereby to liberate the evil spirits that caused those headaches."31Here, he redirected the focus of the figure's identity from brutish and primitive, to suffering and sick.He sought to focus on the sensitivity of a figure who seemed to represent the exact opposite, the brutish ancestor to the civilised gentleman.The idea of the atavistic figure as one capable of experiencing pain is particularly pertinent.Nineteenthcentury medicine had come to understood pain principally as an action of the nerves.32As an emergent experimental physiology investigated the actions of the nervous system in producing such physical pains this also took on broader cultural meanings.33As Rachel Ablow notes, pain in the nineteenth century was often tied to evolutionary ideas, particularly the sensitivity of the nervous system.She quotes from a nineteenth-century physician A. St. Claire Buxton; "We see in pain the expression of a high degree of sensibility in the nervous system; and we believe the nervous system has attained its present high degree of sensibility by reason of long and steady development-evolution in fact."34If pain then was understood as a highly developed nervous response, then it was an exemplar of a civilised nature.Thus, Mark's reading of the Neanderthal body as one in pain seems to be a rejection of atavism as threat and a plea for the experience of civilisation in an uncivilised body.Nevertheless, in including Keith's measurements and diagram Mark made himself into a potential subject of cultural anxiety in a period in which discourse on the degeneration Nuncius (2023) 1-27 | 10.1163/18253911-bja10072 of humankind was prevalent.By deconstructing his own idealised norms of turn-of-the-century medical masculinity through this atavistic fantasy he reorientated the focus from the physical to the sensorial in his account.
The conceptual distance between Fildes' gentle doctor standing post over his young patient and the stricken Neanderthal was collapsed by Mark's work.He continually tested the boundaries of both imagined identities in order to bring his reader's attention back to the sensorial.At one moment he lamented the toll his disease has taken on the visible markers of masculinity like his moustache and frock coat, and at the next seemed to cast it off entirely and imagine himself not as the sympathetic yet reserved hero doctor of Fildes' painting, but as an atavistic brute joyously bludgeoning in his own aching head.In abandoning aspirations of a gentlemanly professional identity in this way he revealed it as mere surface adornment, asking readers to see beneath the artifice of civility and experience the barbarism wrought by disease.In doing so, he invited his reader from merely seeing, to feeling.

The Doctor's Body
As eager as he was to focus on sensation rather than vision in defining his acromegaly, Mark could not wholly ignore the visible changes his body was undergoing.By the time he published Acromegaly the medical profession had developed a fascination with the titular condition and journals published case studies often.Where Mark's account focused on his various aches and pains, these featured less in the journal case histories as they were of only trifling importance in diagnosing the disease.The diagnostic centrality of the physical enlargement of the head, hands and feet had been established from Pierre Marie's first cases and inscribed in the very name acromegaly.With such a clear and unusual set of physical symptoms the body of the acromegalic was a subject of fascination.It was one marked by unusual growth and size but a paradoxical physical weakness.For Mark this encroaching weakness meant gradually giving up much of his day-to-day professional practices both as a physician and as a pathological artist.His identity as a doctor was not only one defined by the idealised imaginings of masculine sympathy explored above, but the embodied skills needed to practice.Indeed, most of his writing that explicitly addresses medical work was centred on his growing physical inability to perform it.In this section, I explore how Mark wrote about his body, the ways in which he used and deconstructed ideas of physical masculinity to reorient his reader away from focusing on the body and back onto the experience of disease.Mark did make himself a spectacle but a particular kind of one.He had to commodify his body in order to make it productive in a capitalist medical society.
In writing about his body, Mark focused not on the growth, or the size, but on the attendant weakness.He seemed to lament the loss of the sort of physically vigorous masculinity prized by the upper classes in the late nineteenth century.36He wrote fondly of his sporting and physical prowess in his youth noting that, when "comparing myself to the young Frenchmen that I mixed with, I was certainly above the average in physical strength and hardiness."37Such ideal qualities were highly sought after by medical men.An 1892 bmj editorial on medical careers emphasized an ideal balance of brains and brawn for the medical graduate asserting that "we have no desire to limit either his reasonable pleasures and relaxations, nor to make him a mere bookworm or a fad; his first lessons in physiology and his common sense will teach him how necessary it is to keep the body in vigorous health if the mind is to be equal to the demands made upon it."38The acromegalic body though was not capable of the sort of sporting physicality desired by men of medicine.Mark then had to make himself and his body useful to medicine in other ways.
Following the 1912 publication of Acromegaly, Mark became something of an expert by experience on the condition whom other sufferers and interested practitioners sought out, with one colleague telling him that he "ought to be looked upon as a sort of receiving house in London of the victims of the com- plaint."39Whilst writing Acromegaly he had expected that he would die from his condition soon after.However, he went on to defy his own expectations and in 1927 he published an essay titled The Apologia of an Acromegalic in which he quipped that "[t]he conclusion I have come to is that, like King Charles ii, I have been a most unconscionable time dying."40Apologia largely dealt with his interactions with other acromegalics, and Mark seemed especially pleased with how he was able to help them, as well as his medical colleagues, to better understand the disease.In one instance, he recounted visiting an infirmary patient exhibiting "the most striking case of acromegaly I have ever seen, with hands which could only be described, as the Germans would say, as colossal." The patient complained to Mark that he had to carry heavy coals to the wards, Mark spoke with his master who said judging by the size of his hands he was very strong.Mark pointed out the patient's small muscles and "assured him the man must be as weak as a kitten."On Mark's advice the patient was found a more suitable job, chopping wood.41 Mark's writing on acromegaly can be seen as an attempt to reassert a productive masculinity in terms of intellect in order to make up for his diminishing physical abilities.He not only helped explain the condition, but in writing Acromegaly and Apologia made himself into a productive medical case study.Numerous colleagues noted how useful Mark had made himself in this way.Surgeon D' Arcy Power (1855Power ( -1941) ) wrote in praise of Mark in the Lancet noting that he meticulously traced his physical and mental symptoms in life, and "to complete the record he left directions that his skull and brain should be examined after death by a competent pathologist."42Mark's book then was placed in a lineage of material evidence that began with his own descriptions and visual representations of his body and ended with the inspection of his bodily material by other experts.
We might easily read this within the wider context of late nineteenthcentury industrial capitalism.As Cindy Lacom has written, "[t]hose unable to meet industrial workplace standards because of a disability or deformity were increasingly exiled from the capitalist norm, which demanded 'useful' bodies, able to perform predictable and repeated movements."43Mark's repeated stressing of his own inabilities to perform as a doctor, his frequent withdrawals 10.1163/18253911-bja10072 | Nuncius (2023) 1-27 from medical and museum work certainly challenged the physical norms of medical practice.His own commodification of his embodied identity as acromegalic doctor reasserted his authority as both and re-established the masculine intellectual authority of the doctor even in the face of the unproductive weakness of his body.Mark's authority was sanctioned because of his medical training, and because of his own agency in using his unproductive body productively in the cause of medical knowledge.
Part of this commodification though was the unavoidable requirement to allow himself to become a spectacle.Indeed, Mark expressed a plaintive awareness of his own body as one that had become an object of public fascination.He wrote that, when walking in public, "should a group of young women pass by, and should they be of that age when maids are wont to giggle, I become aware that their brains contain a centre capable of being stimulated by something in my appearance."44This awareness was not unique to Mark.One Lancet case history concerning a 42-year-old acromegalic woman noted that "[f]or the last seven or eight years she has not cared to go out at all, because people 'looked at her so.'"45A public fascination with giants and other spectacular bodies on display at nineteenth-century freak shows and circuses has been well noted by historians, as has the fact that the medical profession were by no means exempt from this fascination.46Indeed, the preoccupation of the medical authorities with the physicality of the acromegalic was palpable and the written descriptions of patients often betrayed a more intense fascination with their appearance than might have been strictly clinically useful; "[t]he attention is at once arrested by the patient's generally enlarged and massive-looking head" began one typical account.47 However, Mark's visual creation of himself as a spectacle is notably different to these cases.The images he used to represent himself throughout the book thoroughly resisted the visual spectacle of the giant.Mark used a series of eight photographic portraits to illustrate his account.The first four show him up to the age of twenty-five, around the time his symptoms began and in them we see the generally healthy childhood that Mark recalled in the early body-type that arrested Mark's attention and even when ostensibly identifying Punch as an acromegalic by reference to his physical form Mark took pains to stress that the acromegalic experience was dominated by less obvious sufferings.He saw in Punch's behaviour a manifestation of the terrible headaches that afflicted the acromegalic, asking: "[i]s not the way in which he belabours the sconce of poor Judy a symptom of his trouble?"50Just as he had with the imagined acromegalic Neanderthal, Mark focused on behaviour over bodies, inviting the reader to look beyond the visible and once again engage with the sensorial.
This was again obvious in the final chapter of Acromegaly in which he offered a contemplation on a thirteenth-century stone carving on Reims Cathedral which took the form of a stooped female figure cradling her head in her hands (Fig. 6).He noted that medical colleagues had described this figure, with her oversized hands, broad shoulders, and large nose, as potentially acromegalic.Mark though saw something more in the statue; from the hunched position of her body and the large hand clasped to the forehead he imagined that the woman was experiencing some terrible headache and that her suffering was probably worsened by her position overlooking the streets of Reims.He himself wrote of experiencing difficulties in dealing with the expectations of everyday society and when his symptoms were particularly bad he expressed the strong desire to be alone and still.He suffered "[i]ntolerance of any noise or din.Intolerance of any strong light, of the glare of the sun reflected off the pavement when out of doors, or the light reflected from a white table cloth, or from the forks and spoons lying on the dinner-table."51Mark thought empathetically of the Reims statue and the discomfort which her outdoor position might have provoked."The turmoil and the din may have done nothing but aggravate that headache.Perchance she was thankful when the sixty-two years of Louis xiv's reign allowed the old city to rest for that long period in its usual state of dreamy quietude, undisturbed by another coronation."52His meditation on this statue reads as an attempt to communicate, translate, and thus validate the pains he himself suffered so greatly.He wanted readers to see this stone statue not as a spectacle of outsized extremities, but as a body in pain.In including the photograph, the only image in the book that does not show his own body, Mark invited readers to empathise with the stone figure, to feel how our bodies might become rock-like and split apart while we claw at our heads in pain.Though in these two cases Mark focused on behaviours, he also saw similarities between their specific materialities and that of his own acromegalic body.In so readily seeing both the Reims statue and Punch as acromegalics Mark wrote himself into an imaginative lineage with the inanimate materials of stone statue and wooden puppet.In reference to Punch he made this analogy explicit, writing that "[o]nly the other day, while pondering over the changes taking place in my own lower extremities, and the lifeless condition which they are gradually assuming, I was struck by their similarity to those of the marionette which we see dangling in the show."53Mark then completed his project of making his body useful.No longer able to embody the ideal of a vigorously healthy doctor, he had to fulfil the physical promises of his medical masculinity some other way.He made his body into an object for medical study on his own terms, both explicitly-in bequeathing his body for post-mortem study-and implicitly, by aligning himself with other spectacular bodies in order to once again encourage a multi-sensorial understanding of acromegaly.

Sensing beyond Observing
Mark's remarks on art, his own skilled drawings, and his meticulous diary entries suggest that he was certainly a keen observer, yet he also seemed to be something of a deficient diagnostician.In 1890 a student of Pierre Marie's, the Brazilian physician José Dantas Souza-Leite (1859-1925), described the physical changes seen in acromegaly concluding that "it will be seen that there is a distinct diagnostic type of face."54This idea would come to haunt Mark as, following his own self-diagnosis at the age of fifty, he noted with amazement that he had not realised it sooner."For some fifteen or twenty years," he wrote, "each day when I looked into the glass to brush my hair or to shave, there was a typical acromegalic literally staring me in the face."55  the French physician as a "typical acromegalic."56One of the core skills of both the doctor and artist was observation, and in his own case Mark had ostensibly failed.However, his overlooking of his obvious outward symptoms once again can be read as a resistance to being defined purely by the visible.As with the use of his photographs and his discussion of Punch and the statue at Reims, Mark's thoughts on observation frequently indicated that he considered observation alone insufficient in understanding acromegaly.Instead, he invited his readers into the sensory world of the acromegalic through strategies that refocused his observation, and those of his medical colleagues, away from the visible and onto the invisible symptoms and changes he experienced.
As already noted, very soon after its recognition and naming the diagnosis of acromegaly became almost totally predicated on observable 'objective' symptoms like the abnormal growth, something that was immediately obvious to onlookers and did not require explanation by the patient.This was in spite of the fact that hypertrophy alone was rarely what prompted patients to seek medical attention.In fact, in many cases it seemed as though hypertrophy was of little or no concern to the patient, or that they had not even noticed it until friends or family pointed it out.One physician in 1895 recounted that "[f]or about two years the patient's friends had noticed that his face had altered in appearance owing to an increase in the size of the nose and sinking in of the cheeks."57Another, giving the history of a patient who had presented with the typical acromegalic appearance, noted that "[h]e thought but little of his general condition, and it is uncertain for how long the altered appearance had existed, apparently for many years.His only complaint was his failure of sight, and it was for this he came under treatment."58Mark too had paid little heed to the initial changes in his size, even attributing the growth of his hands to his regular use of dumbbells.59 In giving the history of his own disease, Mark revealed tension between patient experience and medical authority.It is clear that Mark well understood this tension, born as it was out of the need of the diagnosing physician to make sense out of a sick person's narrative.He wrote "[i]t is well known how fallacious the accounts given by a patient of his own symptoms may be, how difficult it is, especially when pain looms largely in his mental horizon, 10.1163/18253911-bja10072 | Nuncius (2023) 1-27 to keep an unbiased mind."60This fallaciousness extended to the sort of language used by patients when describing their pain.As Ablow notes, a recurring characteristic of literary nineteenth-century pain narratives is "the eruption of insistently 'literary' or noninstrumental language.This is not to say that pain 'destroys' language; only that it rearranges common protocols, often becoming lyrical, poetic, or rhapsodic in ways that clearly call attention to themselves as literary."61 Though Mark adopted such a literary tone throughout the book, I suggest that this was in fact a way of instrumentalizing language in order to challenge the medical fixation on the observable as the defining element of his disease.Whilst the physical changes in his face were the prime interest of diagnosticians, the imagery that opened this article of the 'cold stream' and the 'clawing crab' beg the reader to refocus onto the sensations of illness.As Joanna Bourke writes of pain metaphors, they allow sufferers to "move a subject (in this case, the practice of being in pain) from inchoateness to concreteness."62Mark referred to these descriptions as 'shaping fantasies' and they conveyed a sense of his own body as a fragile thing that was oppressed and restricted by his disease.Through these fantasies, we can see Mark inviting from his reader a multi-sensorial engagement with his experience by giving them shape and form beyond surface spectacle.
Interpreting patients' idiosyncratic accounts of their health was a topic of wider concern for the medical profession and there were numerous publications devoted to the art of understanding patients' narratives during diagnosis.63 This was a particularly fraught enterprise when it came to invisible symptoms like pain, with one writer noting that "[i]t will be frequently found that the symptom, such as pain even of the most severe type, is described so vaguely that no definite idea can be obtained in regard to its manner of onset, site, or radiation."64Despite recognising this phenomenon Mark himself was unapologetic in offering a meticulously detailed account of his own pains with little attempt at diagnostic discernment.Indeed, he remarked that "I shall not be surprised if I am accused of ascribing to acromegaly symptoms which others will say have nothing to do with it."65Mark also, perhaps understandably, developed 10.1163/18253911-bja10072 | Nuncius (2023) 1-27 comparing himself to the blind prophets Tiresias and Phineus, Thamyris and Maeonides and lamenting that his blindness has left him 'cut off' from seeing the world as it is.Yet he goes on to say he would much rather see inward, with divine revelation.So much the rather thou, celestial Light, Shine inward, and the mind through all her powers Irradiate; there plant eyes, all mist from thence Purge and disperse, that I may see and tell Of things invisible to mortal sight.69 As Mark, increasingly troubled by failing sight, related to Milton's blindness, this inclusion also suggests that his experience allowed for some inner insight, some revealed or prophetic knowledge of his disease that might have eluded the perfectly sighted eyes of his colleagues.

Conclusion
In his 1906 address to the West London Medical and Chirurgical Society Mark ruminated on prehistoric humans' conceptions of the world around them noting that Man's mind must very early have been impressed with wonder by the phenomena that surrounded him, by the world's beauty, the great questions of life and death, of pain and disease, and to this feeling must soon have been added the desire to give form, in some sort of way, to his impressions, so that they might live for others.Words were the first means of expression that came to him, and poetry the first art his intellect created to give shape and colour to his thoughts.70 The notion of communication as creating something that lived for others, that had 'shape and colour' is profoundly multi-sensorial.Reading Acromegaly in light of these musings we can better grasp the potential Mark saw in his prose and imagery in helping his reader to engage sensorially with his account.A key element through which Mark's haptic evocations were constructed was nineteenth-century anxieties around gender, class, and the body.His identity drifted somewhere between the stoic gentleman physician and the uncivilised brute of prehistory.He offered his body up as a spectacle not of size but of weakness; allowing it to be seen as unmanly, unruly to the point of becoming un-human even, and something closer to a statue or marionette.Throughout Acromegaly, Apologia and his other writings, Mark's account of his experience challenges assumptions about how bodies might be governable by any binaries or boundaries when touched by pain.Pain dissolves so much.Once assumed certainties like gender, the lines between fiction and reality, between healthy and well, all fall apart when we are in pain.The distance between past and present collapses and Neanderthal spectres emerge clutching their heads as we clutch our own in sympathetic recognition.

69
John Milton, "Prologue Book iii," in Paradise Lost (Minneapolis, US: Lerner Publishing Group, 1984), 69.70 Mark, Art and Medicine, 5. Downloaded from Brill.com 12/17/2023 01:05:37PM via Open Access.This is an open access article distributed under the terms of the CC BY 4.0 license.https://creativecommons.org/licenses/by/4.0/Nuncius (2023) 1-27 | 10.1163/18253911-bja10072 Downloaded from Brill.com 12/17/2023 01:05:37PM via Open Access.This is an open access article distributed under the terms of the CC BY 4.0 license.https://creativecommons.org/licenses/by/4.0/ Mark's colleagues evidently had much less trouble recognising his condition based on the changes in his appearance.Following his self-diagnosis, he consulted his medical friends only to discover that most of them had already diagnosed his acromegaly several years earlier.Most damning of all, Mark even came to discover that whilst attending a lecture in Paris given by Pierre Marie himself, he was pointed out by Nuncius (2023) 1-27 | 10.1163/18253911-bja10072