In 1899, a Philadelphia pediatrician was called to the home of a seventeen-year-old patient who was having "an hysterical attack." Dr. Edwin Rosenthal had seen "Miss E.L." before, because she suffered from headaches and irregular periods. But this time the young woman, who was studying to be a teacher, was agitated and sobbing about her skin. She had acne on each cheek and claimed that "pimples [were] the bane of [her] life."
Dr. Rosenthal's patient was obviously preoccupied with how she looked. Like many adolescent girls, past and present, she was sufficiently self-conscious that a crop of pimples brought her to tears. In order to defuse her anxiety, Rosenthal fashioned a therapy suited to both her medical and emotional needs: he treated her with purgatives and Gudes Pepto-Mangan, an iron supplement. (These were standard, minimally effective fare at the time for handling gastric and menstrual disorders, believed to cause adolescent acne.) Because he knew that "E.L." would do almost anything to rid herself of the embarrassing blemishes, Rosenthal was confident that she would take her medicine. "Vanity came to my assistance," he noted, in describing how he had handled this unhappy daughter of the Victorian middle class.
Pimples are a natural part of biological maturation, but the meaning we give to them is derived from the culture in which we live. According to G. Stanley Hall, young people at the turn of the twentieth century already had a highly developed "dermal consciousness." In his massive study in 1904, Hall reported that adolescents of both sexes had a "strong desire" to remove pimples and sometimes "picked" their skin for hours. But Hall also noted a gender difference in the intensity of adolescent self-scrutiny. It was girls, not boys, who displayed a "new sense of toilet" marked by zealous concern about their hair and skin.
From a historical perspective, adolescent acne was very much a girls' disease until the mid-twentieth century. The reason was simple: girls demonstrated more urgency than boys about pimples. As early as 1885, in the first professional monograph devoted exclusively to acne, L. Duncan Bulkley, a physician at New York Hospital, noted that girls were more likely than boys to seek medical help for the inflammatory form of pustules and blackheads so common in adolescence. Of the nearly three hundred patients he saw in private practice, 78 percent were young women between the ages of ten and twenty-five.
"Acne in all its forms" is "undoubtedly more common in females than in males," Dr. Bulkley concluded, and he provided an insightful explanation: "The very great difference is in part accounted for by the less attention given to the eruption by males." Although most Victorian doctors thought that girls had more acne than boys because of physical weaknesses such as digestive problems, menstrual disorders, and anemia-all believed to be inherent in the female sex-Bulkley understood that it was social and cultural pressures, as much as biological vulnerability, that filled his waiting room with young women rather than young men. Although boys surely suffer from the stigma of acne, girls' pimples get more cultural attention. Because of cultural mandates that link femininity to flawless skin, the burden of maintaining a clear complexion has devolved disproportionately upon women and girls.
In the battle against acne, girls have not fought alone. In fact, skin care was really the first of many body projects endorsed and supported by middle-class parents for their adolescent children. Maternal influence over menarche and menstruation declined in the twentieth century, but parental intervention in cases of acne increased. This exchange says a great deal about the cultural priorities of middle-class mothers, who increasingly invested themselves and their money in external aspects of their daughters' bodies: aspects, like skin, which were as public as clothes.
American parents cooperated with a body project like skin care because they understood that good looks were an important vehicle of social success for their daughters. Twentieth-century medicine made clear skin in adolescence a priority and also a possibility. Until then, medical treatment for acne was considered either a luxury or unimportant, because acne was never life-threatening. In the nineteenth century, many Americans still had skin that was scarred as a result of smallpox (which left pitting) or tuberculosis (which stimulated acne). In contrast to those who suffered with "real" diseases like these, unhappy adolescent girls like Miss E.L. seemed shallow and less than deserving.
But attitudes began to change in the twentieth century, when modern dermatology and pediatrics began to take adolescents and their blemishes seriously. Attention to acne was justified by the new idea that pimples could be destructive to the mental health of young people. For the field of dermatology, recognition of the emotional anguish of adolescent acne was good news: acne now promised to be a lucrative staple of the trade, one that would exist as long as girls and families cared deeply about their looks. Medical intervention was also important for girls, however, because it stimulated new drugs and treatment strategies that effectively reduced both acne and scarring from it. As concerns about beauty and disease merged, the pursuit of perfect skin-one of the most common adolescent body projects-was transformed into a legitimate health strategy deserving of adult support, and generating enormous profits for both the cosmetic and the drug industries.
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