THE DANGERS OF DRESS: MEDICAL HAZARDS IN

FASHION AND FADS*

Throughout the ages men and women have done many things with
their bodies to be fashionable, often with harmful effects on their health.
Most noteworthy was the custom of foot binding, which flourished for
one thousand years, leaving millions of Chinese women crippled for life
(1, 2, 3). Between the ages of 5 and 7 a girl's feet were strapped and
treated daily for three or more years until they reached the desired length
of 31/2 to 4 inches. Initially the outer toes were flexed upon the sole and
the metatarsals firmly pressed together. Later the forefoot was manipu-
lated into a plantar flexed position. During the binding the feet were
encased in special shoes which became smaller and smaller as the
bandages were tightened. Ultimately, the foot assumed the shape of a
cone and resembled a pes cavus, with a high instep and a prominent,
vertically placed heel. The deformity severely limited a woman's ability
to walk and it became fashionable to be carried in a sedan chair. Foot
binding was extremely painful, especially during the daytime when the
young girls were forced to walk on their compressed feet to promote the
circulation of blood. At night they dangled their legs over the edge of the
bed, exerting pressure on the popliteal fossa in an attempt to numb the
excruciating pain.
Because the washing and binding of feet were done in the strictest
privacy, a woman's foot was considered the most intimate part of her
body and a powerful focus of sex appeal. Bandages were loosened only in
moments of deep intimacy and fondling the feet figured largely in sex
play. In China during the 19th century a photograph of an unbound foot
was felt to be pornographic. The foot fetish made the humble shoe the
most important part of a woman's costume. Chinese shoes were con-
structed of beautiful fabric, and were embroidered lavishly (Figure 1).
Modern shoes with tall, spiked heels and toes tapering to needle points
temporarily deform feet in a manner not unlike that achieved perma-
nently by binding. Elevation of the heel shoves the toes forward, placing
increased pressure on the ball of the foot, thereby encouraging the
development of corns, bunions, calluses, ingrown toe nails and hammer
*
From the Department of Medicine, School of Medicine, University of Pennsylvania,
Philadelphia, Pennsylvania.
** Requests for reprints should be sent to Truman G. Schnabel, 196 Gibson, Hospital of
the University of Pennsylvania, 36th & Spruce Streets, Philadelphia, Pennsylvania 19104.
183
184 TRUMAN G. SCHNABEL

FIG. 1. 19th century embroidered Chinese shoe measuring 5 inches in length. Philadelphia
Museum of Art.

toes. A 31/2 inch heel reduces the leverage of the foot approximately 28%
and increases the likelihood of sprained ankles (4).
Older than the custom of foot binding is the binding of the female
torso to create a small waist. Greek and Roman women slimmed their
abdomens with wrappings and bandages, while Renaissance ladies wore
corsets of cast iron, hinged on the sides (5). At the beginning of the 19th
century, the rigid corset was supplanted by a more pliable one.
Men as well as women wore corsets (6). Disraeli's stays are said to
have been visible through his coat. Girls of two and three were corseted
during sleep lest their waists grow during the night. A 13-inch waist was
greatly prized (7). Courtesans, show girls and vain women sometimes had
their lower ribs removed to achieve a wasp like figure. For others, there
was no surcease from the relentless abdominal pressure, even while
swimming.
Many illnesses were ascribed to the practice. The unyielding busks
worn by Marie Antoinette, Elizabeth I and their like caused deep excor-
iations that sometimes became infected and led to death. Abortion and
pulmonary hemorrhage were also believed due to these "terrible engines,"
as they were often called. Sommerring (8), the German anatomist wrote
of the dire nature of corsets, attributing to those "engines" cancer,
tuberculosis and scoliosis in those who wore them.
 THE DANGERS OF DRESS 185
Physiologic studies (9) revealed that the torso was subjected to pres-
sures of 30-85 pounds. The circumferences of the lower chest (Figure 2)
and abdomen were decreased, the latter by as much as six inches. The
inferior portions of the lungs were compressed and vital capacity reduced
by approximately 20 percent. The fat and muscles of the abdominal wall
atrophied in some cases to such a degree that peristaltic waves could be
seen clearly through the skin. The liver, at times, filled the entire right
side of the abdomen, its lower edge reaching the iliac crest. Experiments
in guinea pigs (10) suggested that bile flow was decreased by fifty percent.
Constant pressure on the uterus weakened the supporting ligaments,
often leading to prolapse.
More recently, Dr. Paul White, writing about the tight girdle syndrome
(11), told of "being puzzled by finding a vigorous carotid pulse accom-
panied by a jugular pulse visible just above the edge of the right clavicle
in women with no abnormality of the heart and blood vessels. The
phenomenon disappeared upon loosening the girdle." He also described
"gastrointestinal symptoms attributed to hiatal hernia and dyspnea due
to the displacement of the stomach upward and the decrease in thoracic
space"-symptoms and signs which again disappeared once the girdle
was removed.
Today, tight jeans shape the female figure rather than the corsets and
bras of the past. Like the undergarments of old they, too, have been
linked to disease (12).
Vulvoginitis is widespread, with three quarters of the women in the
United States having experienced at least one attack (13). While rarely
requiring hospitalization, it causes considerable suffering and often
strains marital relations.
Two recent studies, one of 365 Nigerian women (14), the other of 203
women in an Indiana family practice clinic (15), report a higher incidence
of yeast vaginitis in the wearers of jeans and panty hose than in women
clothed in loose garments. It is believed that tight clothing limits the
circulation of air, producing a warm, moist environment that is ideal for
the growth of yeast. Local occlusion and maceration predispose women
to candidal overgrowth and infection.
At the end of the 18th century it was the style in France to drape the
female body like Greek and Roman statues so that the form might be
easily seen. The French painter David encouraged the fashion by painting
his subjects, including Madame Recamier, in diaphanous and clinging
clothes. The dresses were made of sheer material, with nothing but a
type of body stocking underneath. They were sometimes put on wet, in
order to outline the body's shape more revealingly (16). When worn
during winter in drafty and poorly heated buildings, women often con-
tracted a serious pulmonary illness called "muslin sickness". Today it
would be diagnosed as pneumonia.
186 TRUMAN G. SCHNABEL

FIG. 2. Female skeleton showing the effects of tight corsetting on the thoracic cage.
Mutter Museum, The College of Physicians of Philadelphia.
 THE DANGERS OF DRESS 187
Fashions in hair styling have been as numerous and varied as those
for the torso and foot. During a period of a hundred years, men, women
and children endured much discomfort and actual damage to their hair
because of the fashionable wig.
Men were the first to wear wigs. Women embraced the fashion more
slowly, but finally did so with enthusiasm and a creativity that knew no
bounds. False hair was built upon wire or balsa wood frames which
towered as high as three feet above the head. Once the ringlets, knots,
rolls and lovelocks were added, the whole creation was patted with sugar
water to keep the hair in place and help the powder cling.
Wigs, which might take a half day to build, were often left undisturbed
for weeks, and even months. Lice and other insects were attracted by the
sugar and became ensnared in the sticky thicket. Scalp sores were
common and itching was intense. What today are called back scratchers
were actually invented in the 18th century to reach up under the wig and
scratch the scalp (17). Among habitual wig wearers, baldness was a
common occurrence.
Far more dangerous than most sartorial fashions is the desire of
modern Caucasians to change the color of their skins by exposure to
ultraviolet light. The custom affects both sexes and all ages. It is of
recent origin, since pale or fair skin was formerly prized. In the 17th
century faces were covered with masks to protect them from the sun and
wind (18). From the 18th to the beginning of the 20th centuries, women
carried parasols, wore deep bonnets and gloves to preserve a fashionable
pallor. Early swimsuits exposed the least possible amount of skin to the
sun's rays (Figure 3). Now, little or nothing is worn on the beach in

FIG. 3. Bathers on the beach at Oak Bluff, Martha's Vineyard, 1888.

FIG. 4. Essay on Tight Lacing written in 1855 by Thomas Tilden for the Degree of Doctor
of Medicine, University of Pennsylvania. Special collections, Van Pelt Library, University
of Pennsylvania.
 THE DANGERS OF DRESS 189
summer. Suntanning parlors are crowded during the dark winter months,
and in the spring the sun is once again sought-sometimes with utter
abandon.
It is well recognized that tanning ages the skin and leads to the
development of deep wrinkles. Numerous epidemiological reports and the
production of skin cancers in mice with ultraviolet radiation (19) are
evidence of the sun's ability to cause basal and squamous cell carcinomas
in humans.
While no animal model exists for malignant melanoma, numerous
studies indicate the important role played by the sun in this skin
malignancy (20). During the past 25 years the incidence of malignant
melanoma has increased in an alarming manner. Mortality rates have
risen more than for any other cancer, except carcinoma of the lung. In
1985 it is predicted that 22,000 people will develop newly recognized
melanomas and 5,500 will die from their malignant spread (21). A terrible
price to pay for a fashionable tan.
Until late in the 19th century, a thesis was required for graduation
from the University of Pennsylvania School of Medicine (Figure 4). In
his dissertation on Health vs. Fashion, Dr. Thomas Corson stated in
1851 that many persons sacrifice health and comfort for the sake of being
in fashion (22). He wrote, "This potent goddness is as changeable as the
wind-at one time counseling votaries to cover themselves with clothes
almost to suffocation, then again going to the other extreme, giving them
hardly enough apparel to hide their nakedness".
So it was then, is now, and ever shall be.
REFERENCES
1. Chan LMV. Foot binding in Chinese women and its psycho-social implications. Canad
Psychiat Assoc J 1970; 15: 229.
2. Mottram ME, Pyle IR. Mandarin feet. Am J Roentgenol Radium NucI Med 1973; 118:
318.
3. Chew MBK. Chinese bound foot. Radiography 1973; 39: 39.
4. Stewart SF. Footgear-its history, uses and abuses. Clin Orthop 1972; 88: 119.
5. Davenport M. The Book of Costume, Vol I. New York: Crown Publishers, Inc; 1948:
442.
6. Kemper RH. Costume. New York: NewsWeek Book; 1977: 121.
7. Kemper RH. Ibid, 130.
8. Schwarz GS. "Sommerring's syndrome? No! Never!" N Engl J Med 1974; 291: 802.
9. Dickinson RL. The corset: questions of pressure and displacement. NY Med J 1887;46:
507.
10. Collins WJ. The effect of tight lacing upon the secretion of bile. Lancet 1888;1:518.
11. White PD. The tight girdle syndrome. N Engl J Med 1973; 288: 584.
12. MIlsom I, Forssman L. Repeated candidiasis: reinfection or recrudescense? A review.
Am J Ob Gyn 1985; 152: 956.
190 TRUMAN G. SCHNABEL
13. Sobel JD. Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis. Am J
Ob Gyn 1985; 152: 924.
14. Elegbe IA, Elegbe I. Quantitative relationships of candida albicans infections and
dressing patterns in Nigerian women. Am J Public Health 1983; 73:450.
15. Heidrich FE, Berg AO, Bergman JJ. Clothing factors and vaginitis. J Fam Prac 1984;
19:491.
16. Laver J. A Concise History of Costume. London: Thames and Hudson; 1969; 152.
17. Laver J. Ibid:141.
18. Kohler C. History of Costume. New York: Dover Publications, Inc; 1963: 320.
19. Kligman LH, Akin FJ, Kligman AM. The contributions of UVA and UVB to connective
tissue damage in hairless mice. J Invest Med Derm 1985; 84: 272.
20. Fitzpatrick TB, Sober AJ. Sunlight and skin cancer. N Engl J Med 1985; 313: 818.
21. Friedman RJ, Rigel DS, Kopf AW. Early detection of malignant melanoma: Physicians'
examinations and self examination of the skin. Ca-A Cancer Journal for Clinicians
1985; 35: 130.
22. Corson T. Health vs. Fashion. Medical dissertation, University of Pennsylvania School
of Medicine, 1851.

DISCUSSION
Southworth (New York): I told Mary she might want a case and that I would produce
one. This is a true story: It was in the winter of 1937-38 when I was a new practitioner of
medicine in New York City that my wife and I were somehow invited to a Ball at the St.
Regis Roof. As always happens to young physicians, someone came and said "Is there a
physician in the house?", and I had to dash off. In the ladies' room, which embarassed me
to begin with, there was a stout female laid out on the floor with a rather narrow waist. I
discovered that she had a perfectly good pulse, but I didn't know what next to do. Nothing
from medical school, nothing from residency immediately came to mind; but then I went
back to a course in English literature in college where the hero in the 19th century novel
came in, saw the heroine prostrate and said "cut her stays". I pulled up the lady's dress,
rolled her over, and, sure enough, she was laced up for a fare-you-well all the way from her
scapulae to her sacrum. I called for a pair of scissors and snipped; she sat up, gave a great
sigh of relief and was well.