Doctor's Review: Medicine on the Move

October 25, 2014
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Corset craze

How fashion and fasting in the 1800s lead
to anorexia nervosa

After all that holiday gorging going on in most Canadian homes over December, the minds of many physicians -- and their patients -- often turn to losing weight this time of year. While getting rid of those extra few pounds created by fruitcakes and latkes is definitely an annoyance, most people consider it a small price to pay for a little seasonal overindulgence. The battle of the bulge becomes far more serious, however, when losing weight turns into a dangerous obsession, 24 hours a day, 365 days a year.

As the latest spate of waifish Hollywood starlets coyly flaunt boney frames draped in gaping size-zero couture, far too many real young women know the truth about this devastating disease: it is decidedly not glamorous. And while anorexia nervosa is indeed an affliction confined for the most part to the developed world, the vast majority of women who suffer from it do not have the funds required to access the kind of intensive, extended treatment needed to treat this stubborn sickness.

Even those who do get treatment usually fail to be cured. They end up, at best, struggling with their weight issues indefinitely, teetering on the brink of starvation, the quality of their lives drastically reduced by the mental and physical side effects brought on by years of malnutrition.

A person is defined as having anorexia nervosa if she or he meets four major criteria: having a distorted body image, an intense fear of gaining weight or becoming overweight, intentionally maintaining a body weight less than 15 percent below the ideal and amenorrhea for at least three consecutive months. Unfortunately, anorexia is common; however, due to underreporting, as well as the secrecy and denial surrounding this condition, it's hard to know exactly how many people actually suffer from it. Current estimates suggest that the prevalence rate among women is somewhere between 0.5 and 3.7 percent in Western countries. Roughly 90 to 95 percent of people with anorexia are female, with a mean age of onset of 17. Sadly, between five and 20 percent of all patients will ultimately lose their battle with the disease, making it one of the deadliest psychiatric disorders.

CORSETS, OF COURSE
It isn't the first time this frustrating condition has run rampant among young women. During the 19th century -- perhaps the only other period in history when the size and shape of the female form were as widely opined upon as it is today -- a woman was nothing without her waspish waistline. Yes, if ever there was a fashion trend that changed the course of medical history, the corset was it.

At the time, England's prim and proper attitude towards sex had a trickle-down effect that compromised the health of the nation. The common wisdom dictated that women who ate a lot, especially in public, were also wildcats in the bedroom. Those who could not control their appetite for food were similarly powerless against their appetite for sex. Nobody wanted to give the false impression that they were unable to restrain themselves, lest the nation descend into debauchery and immorality, so thin became the ideal. Painfully thin would be a better way to describe it, since the popular but cruel whale-boned corsets of the day reduced women's waists to grotesque proportions and distorted the growth of teenage girls everywhere.

This dreadful garment, particularly favoured by women in the upper levels of society, was an extreme in itself. It employed a structural support network of fabric reinforced by whale baleen and even steel, with laces tightened by one's dressing maid to the point of near-death. Even children were given training corsets from a very young age to prepare them for the rigors of the real thing. Of course, the less body fat there was to displace, the easier it was to wear the corset -- and the more desirable the silhouette -- so legions of young ladies added self-starvation into the mix. By the age of 14, respectable young women were expected to be in full corsets, the constricting garment restricting any last possible chance at child-like play or comfort. Life, from then on, was stiff.

The combination of fasting and fashion -- as well as organ damage in the form of liver, lung and stomach displacement caused by "tight-lacing," as it was called -- had Victorian women everywhere fainting and swooning their lives away. It actually got to the point where women were not able to support the weight of their upper bodies without their corset, so weakened and distorted did their ribcages and spines become over time. The ideal waistline was bearing down on 50 centimetres, but the smaller the better. Stories abounded of girls dying from their livers being punctured by their own ribs, or livers and stomachs being slowly cut in half by too-tight corsets, though no actual proof exists.

 

Many physicians decried the practice, and great public debates ensued about the safety of corseting and the habits of self-starvation it encouraged. Still, few doctors did anything about it, nor could they had they wanted to. The fact was, men of the day were charmed by tiny waists, as well as impressed by the degree of suffering women endured to achieve it on their account.

THE TROUBLE WITH TIGHT-LACING
It wasn't until tight-lacing -- and the anorexic tendencies that accompanied it -- became an epidemic, in around the 1890s, that physicians began to speak out more vigorously against it. A few changes in the style of corsetry temporarily eased the pain, but eventually the bustless Edwardian corsets (and the coveted, hollow-backed "s-line" silhouette they aspired to at the turn of the century) were revealed as equally damaging for the injury they caused to the spine and hips. It would take gradually changing fashion trends, World War One and women's liberation to finally kill the corset dead -- though one might argue that the endless hours at the gym required to look good in today's figure-hugging styles are at least as painful as an old-fashioned corset!

Despite the obvious downsides of starving themselves nearly to death, 19th-century women were praised for their moderation and self-control, much as those who emulate emaciated runway models are today. Even though their dangerous habits are decried by their parents, friends and physicians, the media images and social ideal that thinness represents are strong reinforcements. During the Victorian era, when few freedoms were afforded the average teenage girl, the one thing she could control was her weight. And since the doctors treating these girls never made the leap between social norms and the disease they caused, treating it effectively was nearly impossible. Countless young women suffered from anorexia nervosa and the medical community couldn't do a thing to stop it.

FINDING FASTING FASCINATING
England was the centre of the universe in the 19th century, and her influence in all things spread like wildfire. All over Europe, thin was in. Denial that the British Empire's female youth were starving themselves to death ran deep, so much so that the first published account of the problem came from a French neuropsychiatrist named Ernest-Charles Lasègue (1816-1883) in 1873. His L'Anorexie hysterique recounted how the condition was prevalent among the young women of France. Lasegue described three stages of anorexia, accurately characterizing it clinically in much the same way as psychiatrists do today.

A few years earlier, in 1868, famed English physician Sir William Withey Gull (1816-1890) -- who counted Queen Victoria among his patients -- actually alluded to an anorexia-like condition in one of his papers, though it wasn't until 1873, the same year as Lasègue's book, that he presented a paper to the Clinical Society of London describing a case study and coining the term "anorexia nervosa." He identified sufferers as young women between the ages of 16 and 23, who refuse food without any underlying organic cause, despite being completely sane otherwise. Though Gull was on Scotland Yard's shortlist of Jack the Ripper suspects, his contributions to medicine are much appreciated.

The first picture of a girl with anorexia appeared in 1932, in the New England Journal of Medicine. It remained a relatively rare problem throughout the 20th century, until the death of singer Karen Carpenter in 1983 garnered much media attention, raised awareness and pushed the problem back into the fore of the public mind just as the trend began to take hold of teenage girls once again, much as it had 150 years earlier.

THE WEIGHT OF THE WORLD
The good news is that Victorian preferences and contemporary customs are likely just blips on the radar. A quick tour of your local art museum will reveal that the world's perception of the perfect female body has stayed pretty much the same over the ages -- a predilection for the pleasantly plump, for the most part. After all, what's sexier than healthy? Across all religions and cultures, motherhood is exalted as nearly divine, and let's face it: most mothers come with a certain amount of junk in the trunk. From the curvaceous sculptures of ancient Greece and Rome, to Botticelli's full-figured female forms, even the stylized subjects of Picasso, the hourglass shape has pretty much been the ideal overall.

As Victorian preferences gradually morphed into a healthier ideal -- at least for a few decades -- so too might today's troubling trends. But now, as then, anorexia is the result of an extremely complex interplay of social, psychological and physiological factors. Treating the disease as a whole means contending with these issues on a patient-by-patient basis, though hopefully, the social pressure to be thin will eventually fall to the wayside and a healthier, more historical ideal of the feminine physique will emerge once again. That is, unless the next corset craze is just around the corner.

 

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