document_title: Necktie

question_text: when did the modern tie come into fashion

question_tokens: when did the modern tie come into fashion

text: Necktie

text: History[edit]

text: Origins[edit]

text: According to some historical evidence, it seems that the Apollinaion tie has been used by elders and commanders of the Sassanid Corps, and a widespread view of this is seen at the taq bostan in Kermanshah.

text: British scientist Noel Malcolm, in a book on Bosnian history, believes that this tie was first introduced to Europe from the Sasanians to Iran.

text: There is a long history of neckwear worn by soldiers (Roman), whether as part of a uniform or as a symbol of belonging to a particular group. Some form of neckwear other than the outdoor scarf can be traced intermittently through many centuries.

text: The modern necktie spread by Europe traces back to the time of the Thirty Years' War (1618–1648) when Croatian mercenaries from the Croatian Military Frontier in French service, wearing their traditional small, knotted neckerchiefs, aroused the interest of the Parisians.[2] Because of the difference between the Croatian word for Croats, Hrvati, and the French word, Croates, the garment gained the name "cravat" ("cravate" in French).[3] The boy-king Louis XIV began wearing a lace cravat about 1646, when he was seven, and set the fashion for French nobility. This new article of clothing started a fashion craze in Europe; both men and women wore pieces of fabric around their necks. From its introduction by the French king, men wore lace cravats, or jabots, that took a large amount of time and effort to arrange. These cravats were often tied in place by cravat strings, arranged neatly and tied in a bow.

text: International Necktie Day is celebrated on October 18 in Croatia and in various cities around the world, e.g. in Dublin, Tübingen, Como, Tokyo, Sydney and other towns.[4][5]

text: 1680–1710: the Steinkirk[edit]

text: This section does not cite any sources. Please help improve this section by adding citations to reliable sources. Unsourced material may be challenged and removed. (July 2009) (Learn how and when to remove this template message)

text: The Battle of Steenkerque took place in 1692. In this battle, the princes, while hurriedly dressing for battle,[dubious  – discuss] wound these cravats around their necks. They twisted the ends of the fabric together and passed the twisted ends through a jacket buttonhole. These cravats were generally referred to as Steinkirks.

text: 1710–1800: stocks, solitaires, neckcloths, cravats[edit]

text: In 1715, another kind of neckwear, called "stocks" made its appearance. The term originally referred to a leather collar, laced at the back, worn by soldiers to promote holding the head high in a military bearing.  The leather stock also afforded some protection to the major blood vessels of the neck from saber or bayonet attacks.  General Sherman is seen wearing a leather stock in several American Civil War-era photographs.

text: Stock ties were initially just a small piece of muslin folded into a narrow band wound a few times round the shirt collar and secured from behind with a pin.  It was fashionable for the men to wear their hair long, past shoulder length. The ends were tucked into a black silk bag worn at the nape of the neck. This was known as the bag-wig hairstyle, and the neckwear worn with it was the stock.

text: The solitaire was a variation of the bag wig. This form had matching ribbons stitched around the bag. After the stock was in place, the ribbons would be brought forward and tied in a large bow in front of the wearer.

text: Sometime in the late 18th century, cravats began to make an appearance again.[where?] This can be attributed to a group of young men called the macaronis (as mentioned in the song "Yankee Doodle"). These were young Englishmen who returned from Europe and brought with them new ideas about fashion from Italy. The French contemporaries of the macaronis were the incroyables.

text: 1800–1850: cravat, stocks, scarves, bandanas[edit]

text: At this time, there was also much interest in the way to tie a proper cravat and this led to a series of publications. This began with Neckclothitania, which is a book that contained instructions and illustrations on how to tie 14 different cravats. Soon after, the immense skill required to tie the cravat in certain styles quickly became a mark of a man's elegance and wealth.[6]  It was also the first book to use the word tie in association with neckwear.

text: It was about this time that black stocks made their appearance. Their popularity eclipsed the white cravat, except for formal and evening wear. These remained popular through to the 1850s. At this time, another form of neckwear worn was the scarf. This was where a neckerchief or bandana was held in place by slipping the ends through a finger or scarf ring at the neck instead of using a knot. This is the classic sailor neckwear and may have been adopted from them.

text: 1860–1920s: bow ties, scarf/neckerchief, the ascot, the long tie[edit]

text: With the industrial revolution, more people wanted neckwear that was easy to put on, was comfortable, and would last an entire workday. Neckties were designed long, thin and easy to knot, and they did not come undone. This is the necktie design still worn by millions of men.

text: By this time, the sometimes complicated array of knots and styles of neckwear gave way to the neckties and bow ties, the latter a much smaller, more convenient version of the cravat.  Another type of neckwear, the Ascot tie, was considered de rigueur for male guests at formal dinners and male spectators at races. These ascots had wide flaps that were crossed and pinned together on the chest.

text: This was until 1926, when a New York tie maker, Jesse Langsdorf came up with a method of cutting the fabric on the bias and sewing it in three segments. This technique improved elasticity and facilitated the fabric's return to its original shape. Since that time, most men have worn the "Langsdorf" tie. Yet another development during that time was the method used to secure the lining and interlining once the tie had been folded into shape. Richard Atkinson and Company of Belfast claim to have introduced the slipstitch for this purpose in the late 1920s.

text: After the First World War, hand-painted ties became an accepted form of decoration in the U.S.[citation needed] The widths of some of these ties went up to 4.5 inches (11 cm).  These loud, flamboyant ties sold very well all the way through the 1950s.

text: In Britain, regimental stripes have been continuously used in tie designs at least since the 1920s. In Commonwealth countries, necktie stripes run from the left shoulder down to the right side. In Commonwealth countries, only people affiliated with a regiment (or university, school or organisation) should wear a necktie affiliated with that regiment. When Brooks Brothers introduced similar striped ties in the United States around the beginning of the 20th century, they had their stripes run from the right shoulder to the left side, in part to distinguish them from British regimental striped neckties.

text: Before the Second World War ties were worn shorter than they are today; this was due, in part, to men wearing trousers at the natural waist (more or less at the level of the belly button), and also due to the popularity of waistcoats, where tie length is not important as long as the tips are concealed. Around 1944, ties started to become not only wider, but even more wild. This was the beginning of what was later labeled the Bold Look: ties that reflected the returning GIs' desire to break with wartime uniformity. Widths reached 5 inches (13 cm), and designs included Art Deco, hunting scenes, scenic "photographs", tropical themes, and even girlie prints, though more traditional designs were also available. The typical length was 48 inches (120 cm).

text: The Bold Look lasted until about 1951, when the "Mister T" look (so termed by Esquire magazine) was introduced. The new style, characterized by tapered suits, slimmer lapels, and smaller hat brims, included thinner and not so wild ties. Tie widths slimmed to 3 inches (7.6 cm) by 1953 and continued getting thinner up until the mid-1960s; length increased to about 52 inches (130 cm) as men started wearing their trousers lower, closer to the hips. Through the 1950s, neckties remained somewhat colorful, yet more restrained than in the previous decade. Small geometric shapes were often employed against a solid background (i.e., foulards); diagonal stripes were also popular. By the early 1960s, dark, solid ties became very common, with widths slimming down to as little as 1 inch (2.5 cm).

text: The 1960s brought about an influx of pop art influenced designs. The first was designed by Michael Fish when he worked at Turnbull & Asser, and was introduced in Britain in 1965; the term Kipper tie was a pun on his name, as well as a reference to the triangular shape of the front of the tie. The exuberance of the styles of the late 1960s and early 1970s gradually gave way to more restrained designs. Ties became wider, returning to their 4 1⁄2-inch (11 cm) width, sometimes with garish colors and designs. The traditional designs of the 1930s and 1950s, such as those produced by Tootal, reappeared, particularly Paisley patterns. Ties began to be sold along with shirts, and designers slowly began to experiment with bolder colors.

text: In the 1980s, narrower ties, some as narrow as 1 1⁄2 inches (3.8 cm) but more typically 3 to 3 1⁄4 inches (7.6 to 8.3 cm) wide, became popular again. Into the 1990s, as ties got wider again, increasingly unusual designs became common. Novelty (or joke) ties or deliberately kitschy ties designed to make a statement gained a certain popularity in the 1980s and 1990s. These included ties featuring cartoon characters, commercial products, or pop culture icons, and those made of unusual materials, such as plastic or wood. During this period, with men wearing their trousers at their hips, ties lengthened to 57 inches (140 cm).

text: At the start of the 21st century, ties widened to 3 1⁄2 to 3 3⁄4 inches (8.9 to 9.5 cm) wide, with a broad range of patterns available, from traditional stripes, foulards, and club ties (ties with a crest or design signifying a club, organization, or order) to abstract, themed, and humorous ones. The standard length remains 57 inches (140 cm), though other lengths vary from 117 cm to 152 cm. While ties as wide as 3 3⁄4 inches (9.5 cm) inches are still available, ties under 3 inches (7.6 cm) wide also became popular, particularly with younger men and the fashion-conscious. In 2008 and 2009 the world of fashion saw a return to narrower ties.

text: Types[edit]

text: Cravat[edit]

text: In 1660, in celebration of its hard-fought victory over the Ottoman Empire, a crack regiment from Croatia  visited Paris. There, the soldiers were presented as glorious heroes to Louis XIV, a monarch well known for his eye toward personal adornment. It so happened that the officers of this regiment were wearing brightly colored handkerchiefs fashioned of silk around their necks. These neck cloths struck the fancy of the king, and he soon made them an insignia of royalty as he created a regiment of Royal Cravattes. The word "cravat" is derived from the à la croate—in the style of the Croats.

text: Four-in-hand[edit]

text: The four-in-hand necktie (as distinct from the four-in-hand knot) was fashionable in Great Britain in the 1850s. Early neckties were simple, rectangular cloth strips cut on the square, with square ends.  The term "four-in-hand" originally described a carriage with four horses and a driver; later, it also was the name of a London gentlemen's club, The Four-in-Hand Driving Company founded in 1856. Some etymologic reports are that carriage drivers knotted their reins with a four-in-hand knot (see below), whilst others claim the carriage drivers wore their scarves knotted 'four-in-hand', but, most likely, members of the club began wearing their neckties so knotted, thus making it fashionable. In the latter half of the 19th century, the four-in-hand knot and the four-in-hand necktie were synonymous. As fashion changed from stiff shirt collars to soft, turned-down collars, the four-in-hand necktie knot gained popularity; its sartorial dominance rendered the term "four-in-hand" redundant usage, shortened "long tie" and "tie".

text: In 1926, Jesse Langsdorf from New York City introduced ties cut on the bias (US) or cross-grain (UK), allowing the tie to evenly fall from the knot without twisting; this also caused any woven pattern such as stripes to appear diagonally across the tie.

text: Today, four-in-hand ties are part of men's dress clothing in both Western and non-Western societies, particularly for business.

text: Four-in-hand ties are generally made from silk or polyester and occasionally with cotton.  Another material used is wool, usually knitted, common before World War II but not as popular nowadays. More recently,[when?] microfiber ties have also appeared; in the 1950s and 1960s, other manmade fabrics, such as Dacron and rayon, were also used, but have fallen into disfavour. Modern ties appear in a wide variety of colours and patterns, notably striped (usually diagonally); club ties (with a small motif repeated regularly all over the tie); foulards (with small geometric shapes on a solid background); paisleys; and solids.  Novelty ties featuring icons from popular culture (such as cartoons, actors, or holiday images), sometimes with flashing lights, have enjoyed some popularity since the 1980s.

text: Six- and seven-fold ties[edit]

text: A seven-fold tie is an unlined construction variant of the four-in-hand necktie which pre-existed the use of interlining. Its creation at the end of the 19th century is attributed to the Parisian shirtmaker Washington Tremlett for an American customer.[7] A seven-fold tie is constructed completely out of silk. A six-fold tie is a modern alteration of the seven-fold tie. This construction method is more symmetrical than the true seven-fold. It has an interlining which gives it a little more weight and is self tipped.[citation needed]

text: Skinny tie[edit]

text: A skinny tie is a necktie that is narrower than the standard tie and often all-black. Skinny ties have widths of around 2 1⁄2 inches (6.4 cm) at their widest, compared to usually 3–4 inches (7.6–10.2 cm) for regular ties.[8] Skinny ties were first popularized in the late 1950s and early 1960s by British bands such as the Beatles and the Kinks, alongside the subculture that embraced such bands, the mods. This is because clothes of the time evolved to become more form-fitting and tailored.[2] They were later repopularized in the late 1970s and early 1980s by new wave and power pop bands such as the Knack, Blondie and Duran Duran.[9]

text: "Pre-tied" ties and  development of clip-ons[edit]

text: The "pre-tied", or more commonly, the clip-on, necktie is a permanently knotted four-in-hand or bow tie affixed by a clip or hook, most often metal and sometimes hinged, to the shirt front without the aid of a band around a shirt collar;[citation needed] these ties are close relatives of banded pre-tied ties that make use of a collar band and a hook and eye to secure them.[citation needed] The clip-on tie sees use with children, and in occupations where a traditional necktie might pose a safety hazard, e.g., law enforcement,[citation needed] mechanical equipment operators etc.[11] (see  § Health and safety hazard below).

text: The perceived utility of this development in the history of style is evidenced by the series of patents issued for various forms of these ties, beginning in the late 19th century,[10][12] and by the businesses filing these applications and fulfilling a market need for them. For instance, a patent filed by Joseph W. Less of the One-In-Hand Tie Company of Clinton, Iowa for "Pre-tied neckties and methods for making the same" noted that:

text: many efforts ... in the past to provide a satisfactory four-in-hand tie so ... that the wearer ... need not tie the knot ... had numerous disadvantages and ... limited commercial success. Usually, such ties have not accurately simulated the Windsor knot, and have often had a[n] ... unconventional made up appearance. Frequently, ... [they were] difficult to attach and uncomfortable when worn ... [and] unduly expensive ... [offering] little advantage over the conventional.[13]

text: The Inventor proceeded to claim for the invention—the latest version of a 1930s–1950s product line from former concert violinist Joseph Less, Iowan brothers Walter and Louis, and son-in-law W. Emmett Thiessen evolved to be identifiable as the modern clip-on[14]—"a novel method for making up the tie ... [eliminating] the neckband of the tie, which is useless and uncomfortable in warm weather ... [and providing] means of attachment which is effective and provides no discomfort to the wearer", and in doing so achieves "accurate simulation of the Windsor knot, and extremely low material and labor costs".[13] Notably, the company made use of ordinary ties purchased from the New York garment industry, and was a significant employers of women in the pre-war and World War II years.[14]

text: While the appeal of the pre-tied ties from the perspective of fashion has flowed and ebbed,[citation needed] varieties of clip-on long ties and banded bow ties are still the most common form of child-sized ties in the opening decade of the 21st century.[citation needed]

text: Types of knot[edit]

text: There are four main knots used to knot neckties. In rising order of difficulty, they are:

text:
the four-in-hand knot. The four-in-hand knot may be the most common.
the Pratt knot (the Shelby knot)
the half-Windsor knot
the Windsor knot (also redundantly called the "full Windsor"). The Windsor knot is the thickest knot of the four, since its tying has the most steps.

text: The Windsor knot is named after the Duke of Windsor, although he did not invent it. The Duke did favour a voluminous knot; however, he achieved this by having neckties specially made of thicker cloths.

text: In the late 1990s, two researchers, Thomas Fink and Yong Mao of Cambridge's Cavendish Laboratory, used mathematical modeling to discover that eighty-five knots are possible with a conventional tie (limiting the number "moves" used to tie the knot to nine; longer sequences of moves result in too large a knot or leave the hanging ends of the tie too short). The models were published in academic journals, while the results and the 85 knots were published in layman's terms in a book entitled The 85 Ways to Tie a Tie.[15] Of the 85 knots, Fink and Mao selected thirteen knots as "aesthetic" knots, using the qualities of symmetry and balance. Based on these mathematical principles, the researchers came up with not only the four necktie knots in common use, but nine more, some of which had seen limited use, and some that are believed to have been codified for the first time.

text: Other types of knots include:

text:
the small knot (also "oriental knot", "Kent knot"): the smallest possible necktie knot. It forms an equilateral triangle, like the half-Windsor, but much more compact (Fink–Mao notation: Lo Ri Co T, Knot 1). It is also the smallest knot to begin inside-out.
the Nicky knot: an alternative version of the Pratt knot, but better-balanced and self-releasing (Lo Ci Ro Li Co T, Knot 4). Supposedly named for Nikita Khrushchev, it tends to be equally referred to as the Pratt knot in men's style literature. This is the version of the Pratt knot favored by Fink and Mao.
the Atlantic knot: a reversed Pratt knot, highlighting the structure of the knot normally hidden on the back. In order for the wide blade to remain in front and rightside-out, the knot must begin rightside-out, and the thin end must be wrapped around the wide end. (Ri Co Ri Lo Ci T; not catalogued by Fink and Mao, but would be numbered 5r according to their classification.)
the Prince Albert knot (also "double knot", "cross Victoria knot"): A variant of the four-in-hand with an extra pass of the wide blade around the front, before passing the wide blade through both of the resultant loops (Li Ro Li Ro Li Co T T, Knot 62). A version knotted through only the outermost loop is known as the Victoria knot (Li Ro Li Ro Li Co T, Knot 6).
the Christensen knot (also "cross knot"): An elongated, symmetrical knot, whose main feature is the cruciform structure made by knotting the necktie through the double loop made in the front (Li Ro Ci Lo Ri Lo Ri Co T T, Knot 252). While it can be made with modern neckties, it is most effective with thinner ties of consistent width, which fell out of common use after the 19th century.
the Ediety knot (also "Merovingian knot"): a doubled Atlantic knot, best known as the tie knot worn by the character "the Merovingian" in the film The Matrix Reloaded. This tie can be knotted with the thin end over the wide end, as with the Atlantic knot, or with the wide end over the thin end to mimic the look seen in the film, with the narrow blade in front. (Ri Co Ri Lo Ci Ri Co Ri Lo Ci T; not catalogued by Fink and Mao, as its ten moves exceed their parameters.)

text: Ties as a sign of membership[edit]

text: The use of coloured and patterned neckties indicating the wearer's membership in a club, military regiment, school, professional association (Royal Colleges, Inns of Courts) et cetera, dates only from late-19th century England.[16] The immediate forerunners of today's college neckties were in 1880 the oarsmen of Exeter College, Oxford, who tied the bands of their straw hats around their necks.[16][17]

text: In the United Kingdom and many Commonwealth countries, neckties are an essential component of the school uniform and are either worn daily, seasonally or on special occasions with the school blazer. In Hong Kong, Australia and New Zealand, neckties are worn as the everyday uniform, usually as part of the winter uniform. In countries with no winter such as Sri Lanka, Singapore, Malaysia and many African countries, the necktie is usually worn as part of the formal uniform on special occasions or functions. Neckties may also denote membership of a house or a leadership role (i.e. school prefect, house captain, etc.).

text: The most common pattern for such ties in the UK and most of Europe consists of diagonal stripes of alternating colours running down the tie from the wearer's left. Note that neckties are cut on the bias (diagonally), so the stripes on the source cloth are parallel or perpendicular to the selvage, not diagonal. The colours themselves may be particularly significant. The dark blue and red regimental tie of the Household Division is said to represent the blue blood (i.e. nobility) of the Royal Family, and the red blood of the Guards.[citation needed]

text: In the United States, diagonally striped ties are commonly worn with no connotation of group membership. Typically, American striped ties have the stripes running downward from the wearer's right (the opposite of the European style).[18] However, when Americans wear striped ties as a sign of membership, the European stripe style may be used.

text: An alternative membership tie pattern to diagonal stripes is either a single emblem or a crest centered and placed where a tie pin normally would be, or a repeated pattern of such motifs. Sometimes, both types are used by an organization, either simply to offer a choice or to indicate a distinction among levels of membership. Occasionally, a hybrid design is used, in which alternating stripes of colour are overlaid with repeated motif pattern.

text: Use by women[edit]

text: Neckties are sometimes part of uniforms worn by women, which nowadays might be required in professions such as restaurants and police forces. In many countries, girls are nowadays required to wear ties as part of primary and secondary school uniforms.

text: Ties may also be used by women as a fashion statement. During the late 1970s and 1980s, it was not uncommon for young women in the United States to wear ties as part of a casual outfit.[19][20] This trend was popularized by Diane Keaton who wore a tie as the titular character in Annie Hall in 1977.[21][22]

text: In 1993, neckties reappeared as prominent fashion accessories for women in both Europe and the U.S.[23] Canadian recording artist Avril Lavigne wore neckties with tank tops early in her career.

text: Occasions for neckties[edit]

text: Traditionally, ties are a staple of office attire, especially for professionals. Proponents of the tie's place in the office assert that ties neatly demarcate work and leisure time.[24]

text: The theory is that the physical presence of something around your neck serves as a reminder to knuckle down and focus on the job at hand. Conversely, loosening of the tie after work signals that one can relax.[24] However, some tech companies have gone the other way and banned neckties in the office, such as in Google[dubious  – discuss], Amazon, Apple, and Ikea.

text: Richard Branson, founder of Virgin Group, believes ties are a symbol of oppression and slavery.[25]

text: Outside of these environments, ties are usually worn especially when attending traditionally formal or professional events, including weddings, important religious ceremonies, funerals, job interviews, court appearances, and fine dining.[26]

text: Opposition to and problems with neckties[edit]

text: This section does not cite any sources. Please help improve this section by adding citations to reliable sources. Unsourced material may be challenged and removed. (July 2016) (Learn how and when to remove this template message)

text: The debate between proponents and opponents of the necktie center on social conformity, professional expectation, and personal, sartorial expression.  Quoting architect Louis Sullivan, Frank Lloyd Wright said: "Form follows function". Applied sartorially, the necktie's decorative function is so criticized.[citation needed]

text: Health and safety hazard[edit]

text: Necktie opponents cite risks of wearing a necktie as argument for discontinuing it. Their cited risks are entanglement, infection, and vasoconstriction. Entanglement is a risk when working with machinery or in dangerous, possibly violent, jobs such as police officers and prison guards, and certain medical fields.[27]  The answer is to avoid wearing neckties, or to wear pre-knotted clip-on neckties that easily detach from the wearer when grabbed. Vascular constriction occurs with over-tight collars. (Another possibility is to tuck a tie into the shirt through the buttoning, but this protects only against the tie being caught and pulled taut.) Studies have shown increased intraocular pressure in such cases, which can aggravate the condition of people with weakened retinas.[28]  There may be additional risks for people with glaucoma. Sensible precautions can mitigate the risk. Paramedics performing life support remove an injured man's necktie as a first step to ensure it does not block his airway. Neckties might also be a health risk for persons other than the wearer. They are believed to be vectors in disease transmission in hospitals. Notwithstanding such fears, many doctors and dentists wear neckties for a professional image. Hospitals take seriously the cross-infection of patients by doctors wearing infected neckties,[29] because neckties are less frequently cleaned than most other clothes. On September 17, 2007, British hospitals published rules banning neckties.[30] In such a context, some instead prefer to use bow ties due to their short length and relative lack of hindrance.

text: In the UK, it is a popular prank to pull someone's tie so that it tightens.  This prank, known as peanutting or "squatknotting", is often used to embarrass the victim and can also be used for more severe bullying. In March 2008, a 13-year-old boy from Oxted, in Surrey, was rushed into hospital with spinal injuries after being "peanuted". He was kept in hospital for three days.[31]

text: Anti-necktie sentiment[edit]

text:
In the early 20th century, the number of office workers began increasing. Many such men and women were required to wear neckties, because it was perceived as improving work attitudes, morale, and sales.
Removing the necktie as a social and sartorial business requirement (and sometimes forbidding it) is a modern trend often attributed to the rise of popular culture.  Although it was common as everyday wear as late as 1966, over the years 1967–69, the necktie fell out of fashion almost everywhere, except where required. There was a resurgence in the 1980s, but in the 1990s, ties again fell out of favor, with many technology-based companies having casual dress requirements, including Apple, Amazon, eBay, Genentech, Microsoft, Monsanto, and Google.[citation needed]

text: In western business culture, a phenomenon known as Casual Friday has arisen, in which employees are not required to wear ties on Fridays, and then—increasingly—on other, announced, special days. Some businesses have extended casual-dress days to Thursday, and even Wednesday; others require neckties only on Monday (to start the work week).  At the furniture company IKEA, neckties are not allowed.[32]

text: An example of anti-necktie sentiment is found in Iran, whose theocratic rulers have denounced the accessory as a decadent symbol of European oppression. In the late 1970s (at the time of the Islamic Revolution), members of the US press even metonymized Iran's hardliners as turbans and its moderates as neckties. To date, most Iranian men in Iran have retained the Western-style long-sleeved collared shirt and three-piece suit, while excluding the necktie. The majority of Iranian men abroad wear neckties.[33]

text: Neckties are viewed by various sub- and counter-culture movements as being a symbol of submission and slavery (i.e., having a symbolic chain around one's neck) to the corrupt elite of society, as a "wage slave".[34]

text: For 60 years, designers and manufacturers of neckties in the United States were members of the Men's Dress Furnishings Association but the trade group shut down in 2008 due to declining membership due to the declining numbers of men wearing neckties.[35]


document_title: Aortic dissection

question_text: when would a stanford type b require surgery

question_tokens: when would a stanford type b require surgery

root

text: Aortic dissection

text: Signs and symptoms[edit]

text: About 96% of individuals with aortic dissection present with severe pain that had a sudden onset. The pain may be described as a tearing, stabbing, or sharp sensation; 17% of individuals feel the pain migrate as the dissection extends down the aorta. The location of pain is associated with the location of the dissection. Anterior chest pain is associated with dissections involving the ascending aorta, while interscapular (back) pain is associated with descending aortic dissections. If the pain is pleuritic in nature, it may suggest acute pericarditis caused by bleeding into the pericardial sac. This is a particularly dangerous eventuality, suggesting that acute pericardial tamponade may be imminent. Pericardial tamponade is the most common cause of death from aortic dissection.[4]

tag: p

text: While the pain may be confused with the pain of a myocardial infarction (heart attack), aortic dissection is usually not associated with the other signs that suggest myocardial infarction, including heart failure and ECG changes.

text: Individuals with aortic dissection who do not present with pain have a chronic dissection.

text: Less common symptoms that may be seen in the setting of aortic dissection include congestive heart failure (7%), fainting (9%), stroke (6%), ischemic peripheral neuropathy, paraplegia, and cardiac arrest.[5] If the individual had a fainting episode, about half the time it is due to bleeding into the pericardium leading to pericardial tamponade.

text: Neurological complications of aortic dissection (i.e., stroke and paralysis) are due to the involvement of one or more arteries supplying portions of the central nervous system.

text: If the aortic dissection involves the abdominal aorta, compromise of the branches of the abdominal aorta is possible. In abdominal aortic dissections, compromise of one or both renal arteries occurs in 5–8% of cases, while mesenteric ischemia (ischemia of the large intestines) occurs 3–5% of the time.

text: Blood pressure[edit]

text: People with an aortic dissection often have a history of high blood pressure; the blood pressure is quite variable at presentation with acute aortic dissection, and tends to be higher in individuals with a distal dissection. In individuals with a proximal aortic dissection, 36% present with hypertension, while 25% present with hypotension. Proximal aortic dissections tend to be more associated with weakening of the vascular wall due to cystic medial degeneration. In those who present with distal aortic dissections, 70% present with high blood pressure, while 4% present with low blood pressure.[citation needed]

text: Severe hypotension at presentation is a grave prognostic indicator. It is usually associated with pericardial tamponade, severe aortic insufficiency, or rupture of the aorta. Accurate measurement of the blood pressure is important. Pseudohypotension (falsely low blood-pressure measurement) may occur due to involvement of the brachiocephalic artery (supplying the right arm) or the left subclavian artery (supplying the left arm).

text: Aortic insufficiency[edit]

text: Aortic insufficiency (AI) occurs in half to two-thirds of ascending aortic dissections, and the murmur of aortic insufficiency is audible in about 32% of proximal dissections. The intensity (loudness) of the murmur is dependent on the blood pressure and may be inaudible in the event of hypotension.

text: Multiple causes exist for AI in the setting of ascending aortic dissection. The dissection may dilate the annulus of the aortic valve, so that the leaflets of the valve cannot coapt. Another mechanism is that the dissection may extend into the aortic root and detach the aortic valve leaflets. The third mechanism is that if there was an extensive intimal tear, the intimal flap may prolapse into the LV outflow tract, causing intimal intussusception into the aortic valve preventing proper valve closure.

text: Myocardial infarction[edit]

text: Myocardial infarction (heart attack) occurs in 1–2% of aortic dissections. The cause of the infarction is involvement of the coronary arteries, which supply the heart, in the dissection. The right coronary artery is involved more commonly than the left coronary artery. If the myocardial infarction is treated with thrombolytic therapy, the mortality increases to over 70%, mostly due to bleeding into the pericardial sac causing pericardial tamponade.

text: Because aortic dissection may present to the emergency room physician similar to a myocardial infarction, the physician must be careful to make the proper diagnosis prior to initiating treatment for myocardial infarction since the treatment regimen for myocardial infarction can be lethal to an individual presenting with aortic dissection.

text: Pleural effusion[edit]

text: A pleural effusion (fluid collection in the space between the lungs and the chest wall or diaphragm) can be due to either blood from a transient rupture of the aorta or fluid due to an inflammatory reaction around the aorta. If a pleural effusion were to develop due to an aortic dissection, it is more commonly in the left hemithorax rather than the right hemithorax.

text: Causes[edit]

text: Aortic dissection is associated with hypertension (high blood pressure) and many connective tissue disorders. Vasculitis (inflammation of an artery) is rarely associated with aortic dissection. It can also be the result of chest trauma. About 72 to 80% of individuals who present with an aortic dissection have a previous history of hypertension.

text: A bicuspid aortic valve (a type of congenital heart disease involving the aortic valve) is found in 7–14% of individuals who have an aortic dissection. These individuals are prone to dissection in the ascending aorta. The risk of dissection in individuals with bicuspid aortic valve is not associated with the degree of stenosis of the valve.

text: Marfan syndrome is noted in 5–9% of individuals who suffer from an aortic dissection. In this subset, the incidence in young individuals is increased. Individuals with Marfan syndrome tend to have aneurysms of the aorta and are more prone to proximal dissections of the aorta.

text: Turner syndrome also increases the risk of aortic dissection, by aortic root dilatation.[6]

text: Chest trauma leading to aortic dissection can be divided into two groups based on cause: blunt chest trauma (commonly seen in car accidents) and iatrogenic. Iatrogenic causes include trauma during cardiac catheterization or due to an intra-aortic balloon pump.

text: Aortic dissection may be a late sequela of cardiac surgery. About 18% of individuals who present with an acute aortic dissection have a history of open-heart surgery. Individuals who have undergone aortic valve replacement for aortic insufficiency are at particularly high risk because aortic insufficiency causes increased blood flow in the ascending aorta. This can cause dilatation and weakening of the walls of the ascending aorta.

text: Syphilis only potentially causes aortic dissection in its tertiary stage.[7]

text: Pathophysiology[edit]

text: As with all other arteries, the aorta is made up of three layers, the intima, the media, and the adventitia. The intima is in direct contact with the blood inside the vessel, and mainly consists of a layer of endothelial cells on a basement membrane; the media contains connective and muscle tissue, and the vessel is protected on the outside by the adventitia, comprising connective tissue.[8]

text: In an aortic dissection, blood penetrates the intima and enters the media layer. The high pressure rips the tissue of the media apart along the laminated plane splitting the inner two-thirds and the outer one-third of the media apart.[9] This can propagate along the length of the aorta for a variable distance forward or backwards. Dissections that propagate towards the iliac bifurcation (with the flow of blood) are called anterograde dissections and those that propagate towards the aortic root (opposite of the flow of blood) are called retrograde dissections. The initial tear is usually within 100 mm of the aortic valve, so a retrograde dissection can easily compromise the pericardium leading to a hemopericardium. Anterograde dissections may propagate all the way to the iliac bifurcation of the aorta, rupture the aortic wall, or recanalize into the intravascular lumen leading to a double-barrel aorta. The double-barrel aorta relieves the pressure of blood flow and reduces the risk of rupture. Rupture leads to hemorrhaging into a body cavity, and prognosis depends on the area of rupture. Retroperitoneal and pericardial ruptures are both possible.

text: The initiating event in an aortic dissection is a tear in the intimal lining of the aorta. Due to the high pressures in the aorta, blood enters the media at the point of the tear. The force of the blood entering the media causes the tear to extend. It may extend proximally (closer to the heart) or distally (away from the heart) or both. The blood travels through the media, creating a false lumen (the true lumen is the normal conduit of blood in the aorta). Separating the false lumen from the true lumen is a layer of intimal tissue known as the intimal flap.

text: The vast majority of aortic dissections originate with an intimal tear in either the ascending aorta (65%), the aortic arch (10%), or just distal to the ligamentum arteriosum in the descending thoracic aorta (20%).

text: As blood flows down the false lumen, it may cause secondary tears in the intima. Through these secondary tears, the blood can re-enter the true lumen.

text: While it is not always clear why an intimal tear may occur, quite often it involves degeneration of the collagen and elastin that make up the media. This is known as cystic medial necrosis and is most commonly associated with Marfan syndrome and is also associated with Ehlers-Danlos syndrome.

text: In about 13% of aortic dissections, no evidence of an intimal tear is found. In these cases, the inciting event is thought to be an intramural hematoma (caused by bleeding within the media). Since no direct connection exists between the true lumen and the false lumen in these cases, diagnosing an aortic dissection by aortography is difficult if the cause is an intramural hematoma. An aortic dissection secondary to an intramural hematoma should be treated the same as one caused by an intimal tear.

text: Diagnosis[edit]

text: Because of the varying symptoms and signs of aortic dissection depending on the initial intimal tear and the extent of the dissection, the proper diagnosis is sometimes difficult to make.

text: While taking a good history from the individual may be strongly suggestive of an aortic dissection, the diagnosis cannot always be made by history and physical signs alone. Often, the diagnosis is made by visualization of the intimal flap on a diagnostic imaging test. Common tests used to diagnose an aortic dissection include a CT scan of the chest with iodinated contrast material and a transesophageal echocardiogram. The proximity of the aorta to the esophagus allows the use of higher-frequency ultrasound for better anatomical images. Other tests that may be used include an aortogram or magnetic resonance angiogram of the aorta. Each of these tests has pros and cons, and they do not have equal sensitivities and specificities in the diagnosis of aortic dissection.

text: In general, the imaging technique chosen is based on the pretest likelihood of the diagnosis, availability of the testing modality, patient stability, and the sensitivity and specificity of the test.

text: D-dimer[edit]

text: A measurement of blood D-dimer level may be useful in diagnostic evaluation. A level less than 500 ng/ml may be considered evidence against a diagnosis of aortic dissection,[1][10] although this guideline is only applicable in cases deemed "low risk"[11] and within 24 hours of symptom onset.[12] The American Heart Association does not advise using this test in making the diagnosis, as evidence is still tentative.[13]

text: Chest X-ray[edit]

text: Chest radiography may demonstrate a change in the morphology of the thoracic aorta which can be seen in aortic dissection. Classically, new widening of the mediastinum on radiograph is of moderate sensitivity for detecting an ascending aortic dissection; however, this finding is of low specificity, as many other conditions can cause apparent widening of the mediastinum.

text: There are several other associated radiographic findings:

text:
The "calcium sign" describes an apparent separation of the intimal calcification from the outer aortic margin by greater than 10 mm.
Pleural effusions, more commonly in descending aortic dissections, and typically left sided.
Other: obliteration of the aortic knob, depression of the left mainstem bronchus, loss of the paratracheal stripe, and tracheal deviation.

tag: ul

text: Importantly, about 12 to 20% of aortic dissections are not detectable by chest radiograph; therefore, a "normal" chest radiograph does not rule out aortic dissection. If there is high clinical suspicion, a more sensitive imaging test (CT angiogram, MR angiography, or transesophageal echo) may be warranted.

text: Computed tomography[edit]

text: Computed tomography angiography is a fast, noninvasive test that gives an accurate three-dimensional view of the aorta. These images are produced by taking rapid, thin-cut slices of the chest and abdomen, and combining them in the computer to create cross-sectional slices. To delineate the aorta to the accuracy necessary to make the proper diagnosis, an iodinated contrast material is injected into a peripheral vein. Contrast is injected and the scan performed using a bolus tracking method. This type of scan is timed to an injection to capture the contrast as it enters the aorta. The scan then follows the contrast as it flows though the vessel. It has a sensitivity of 96 to 100% and a specificity of 96 to 100%. Disadvantages include the need for iodinated contrast material and the inability to diagnose the site of the intimal tear.

text:
CT with contrast demonstrating aneurysmal dilation and a dissection of the ascending aorta (type A Stanford)

Chest CT with descending (type B Stanford) aortic dissection (red circle)

text: MRI[edit]

text: Magnetic resonance imaging (MRI) is also used for the detection and assessment of aortic dissection, with a sensitivity of 98% and a specificity of 98%. An MRI examination of the aorta produces a three-dimensional reconstruction of the aorta, allowing the physician to determine the location of the intimal tear and the involvement of branch vessels, and to locate any secondary tears. It is a noninvasive test, does not require the use of iodinated contrast material, and can detect and quantitate the degree of aortic insufficiency.

text: The disadvantage of the MRI scan in the face of aortic dissection is that it has limited availability and is often located only in larger hospitals, and the scan is relatively time-consuming, which may be dangerous in people who are already very unwell. Due to the high-intensity magnetic fields used during MRI, it is contraindicated in individuals with metallic implants. In addition, many individuals experience claustrophobia while in the MRI scanning tube.

text: Ultrasound[edit]

text: The transesophageal echocardiogram (TEE) is a relatively good test in the diagnosis of aortic dissection, with a sensitivity up to 98% and a specificity up to 97%. It has become the preferred imaging modality for suspected aortic dissection. It is a relatively noninvasive test, requiring the individual to swallow the echocardiography probe. It is especially good in the evaluation of AI in the setting of ascending aortic dissection, and to determine whether the ostia (origins) of the coronary arteries are involved. While many institutions give sedation during transesophageal echocardiography for added patient comfort, it can be performed in cooperative individuals without the use of sedation. Disadvantages of TEE include the inability to visualize the distal ascending aorta (the beginning of the aortic arch), and the descending abdominal aorta that lies below the stomach. A TEE may be technically difficult to perform in individuals with esophageal strictures or varices.

text:
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Aortic dissection with an intramural hematoma as seen on TEE

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Type A aortic dissection[14]

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Type A aortic dissection[14]

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Dissection of both the thoracic and abdominal aorta[15]

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Dissection of both the thoracic and abdominal aorta[15]

text: Aortogram[edit]

text: An aortogram involves placement of a catheter in the aorta and injection of contrast material while taking X-rays of the aorta. The procedure is known as aortography. Previously thought to be the diagnostic gold standard, it has been supplanted by other, less-invasive imaging modalities.

text: Classification[edit]

text:
Classification of aortic dissection

Percentage
60%
10–15%
25–30%

Type
DeBakey I
DeBakey II
DeBakey III

Stanford A (Proximal)
Stanford B (Distal)

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text: Several different classification systems have been used to describe aortic dissections. The systems commonly in use are based on either the anatomy of the dissection or the duration of onset of symptoms prior to presentation. The Stanford system is used more commonly now, as it is more attuned to the management of the patient.

text: DeBakey[edit]

text: The DeBakey system, named after cardiothoracic surgeon Michael E. DeBakey, is an anatomical description of the aortic dissection. It categorizes the dissection based on where the original intimal tear is located and the extent of the dissection (localized to either the ascending aorta or descending aorta or involves both the ascending and descending aorta.[16]

text:
Type I – originates in ascending aorta, and propagates at least to the aortic arch and often beyond it distally. It is most often seen in patients less than 65 years of age and is the most lethal form of the disease.
Type II – originates in the ascending aorta and is confined to it.
Type III – originates in the descending aorta and rarely extends proximally, but will extend distally. It most often occurs in elderly patients with atherosclerosis and hypertension.

text: Stanford[edit]

text: The Stanford classification is divided into two groups, A and B, depending on whether the ascending aorta is involved.[17]

text:
A – involves the ascending aorta and/or aortic arch, and possibly the descending aorta. The tear can originate in the ascending aorta, the aortic arch, or more rarely, in the descending aorta. It includes DeBakey types I and II.
B – involves the descending aorta or the arch (distal to the left subclavian artery), without the involvement of the ascending aorta. It includes DeBakey type III.

text: The Stanford classification is useful as it follows clinical practice, as type A ascending aortic dissections generally require primary surgical treatment, whereas type B dissections generally are treated medically as initial treatment with surgery reserved for any complications.

text: The reason for surgical repair of type A dissections is that ascending aortic dissections often involve the aortic valve, which, having lost its suspensory support, telescopes down into the aortic root, resulting in aortic incompetence. The valve must be resuspended in order to be reseated, as well as to repair or prevent coronary artery injury. Also, the area of dissection is removed and replaced with a Dacron graft to prevent further dissection from occurring. However, type B dissections are not improved, from a mortality point of view, by the operation, unless leaking, rupture, or compromise to other organs, e.g. kidneys, occurs.

text: Prevention[edit]

text: Among the recognized risk factors for aortic dissection, hypertension, dysplipidemia, and smoking are considered preventable risk factors.[1]

text: Repair of an enlargement of the ascending aorta from an aneurysm or previously unrecognized and untreated aortic dissections is recommended when greater than 6 cm (2.4 in) in size to decrease the risk of dissection. Repair may be recommended when greater than 4.5 cm (1.8 in) in size if the person has one of the several connective-tissue disorders or a family history of a ruptured aorta.

text: Management[edit]

text: In an acute dissection, treatment choice depends on its location. For Stanford type A (ascending aortic) dissection, surgical management is superior to medical management. For uncomplicated Stanford type B (distal aortic) dissections (including abdominal aortic dissections), medical management is preferred over surgical.

text: The risk of death due to aortic dissection is highest in the first few hours after the dissection begins, and decreases afterward. Because of this, the therapeutic strategies differ for the treatment of an acute dissection compared to a chronic dissection. An acute dissection is one in which the individual presents within the first two weeks. If the individual has managed to survive this window period, his prognosis is improved. About 66% of all dissections present in the acute phase. Individuals who present two weeks after the onset of the dissection are said to have chronic aortic dissections. These individuals have been self-selected as survivors of the acute episode and can be treated with medical therapy as long as they are stable.

text: Medication[edit]

text: Aortic dissection generally presents as a hypertensive emergency, and the prime consideration of medical management is strict blood pressure control. The target blood pressure should be a mean arterial pressure (MAP) of 60 to 75 mmHg, or the lowest blood pressure tolerated. Initial decreases should be by about 20%.[2]

text: Another factor is to reduce the shear-force dP/dt (force of ejection of blood from the left ventricle). Long-term management of physical, emotional, and psychological stresses are important to controlling blood pressure.

text: Beta blockers are the first-line treatment for patients with acute and chronic aortic dissection. In acute dissection, rapidly acting, titratable parenteral agents (such as esmolol, propranolol, or labetalol) are preferred. Vasodilators such as sodium nitroprusside can be considered for patients with ongoing hypertension, but they should never be used alone, as they generally cause reflex tachycardia.

text: Calcium channel blockers can be used in the treatment of aortic dissection, particularly if a contraindication to the use of beta blockers exists. The calcium channel blockers typically used are verapamil and diltiazem, because of their combined vasodilator and negative inotropic effects.

text: If the individual has refractory hypertension (persistent hypertension on the maximum doses of three different classes of antihypertensive agents), an involvement of the renal arteries in the aortic dissection plane should be considered.

text: Surgical[edit]

text: Indications for the surgical treatment of aortic dissection include an acute proximal aortic dissection and an acute distal aortic dissection with one or more complications. Complications include compromise of a vital organ, rupture or impending rupture of the aorta, retrograde dissection into the ascending aorta, and a history of Marfan syndrome or Ehlers-Danlos syndrome.

text: The objective in the surgical management of aortic dissection is to resect (remove) the most severely damaged segments of the aorta and to obliterate the entry of blood into the false lumen (both at the initial intimal tear and any secondary tears along the vessel). While excision of the intimal tear may be performed, it does not significantly change mortality.

text: The particular treatment used depends on the segment or segments of aorta involved. Some treatments are:

text:
Open aortic surgery with replacement of the damaged section of aorta with a tube graft (often made of Dacron) when no damage to the aortic valve is seen
Bentall procedure — replacement of the damaged section of aorta and replacement of the aortic valve
David procedure — replacement of the damaged section of aorta and reimplantation of the aortic valve
Thoracic endovascular aortic repair, a minimally invasive surgical procedure usually combined with on-going medical management
Replacement of the damaged section of aorta with a sutureless vascular ring connector-reinforced Dacron graft: The vascular ring connector is a titanic ring used as a stent in the vascular graft to achieve a quick, blood-sealed, and sutureless anastomosis. Two furrows on the surface of the ring are for fixation of the vascular graft and the aorta. The tapes used to tie against the ring provide a larger contact surface area than the traditional stitches, thus it provides stronger anastomosis and better surgical results.

text: A number of comorbid conditions increase the surgical risk of repair of an aortic dissection. These conditions include the following:

text:
Prolonged preoperative evaluation (increased length of time prior to surgery)
Advanced age
Comorbid disease states (e.g.: coronary artery disease)
Aneurysm leakage
Cardiac tamponade
Shock
Past history of myocardial infarction
History of kidney failure (either acute or chronic kidney failure)

text: Follow-up[edit]

text: The long-term follow-up in individuals who survive aortic dissection involves strict blood pressure control. The relative risk of late rupture of an aortic aneurysm is 10 times higher in individuals who have uncontrolled hypertension, compared to individuals with a systolic pressure below 130 mmHg.

text: The risk of death is highest in the first two years after the acute event, and individuals should be followed closely during this time period. About 29% of late deaths following surgery are due to rupture of either a dissecting aneurysm or another aneurysm. In addition, a 17% to 25% incidence exists of new aneurysm formation, typically due to dilatation of the residual false lumen. These new aneurysms are more likely to rupture, due to their thinner walls.

text: Serial imaging of the aorta is suggested, with MRI being the preferred imaging technique.

text: Epidemiology[edit]

text: Establishing the incidence of aortic dissection has been difficult because many cases are only diagnosed after death (which may have been attributed to another cause), and is often initially misdiagnosed. Aortic dissection affects an estimated 2.0–3.5 people per every 100,000 every year. Studies from Sweden suggest that the incidence of aortic dissection may be rising.[18] Men are more commonly affected than women: 65% of all people with aortic dissection are male. The mean age at diagnosis is 63 years.[8] In females before the age of 40, half of all aortic dissections occur during pregnancy (typically in the third trimester or early postpartum period).[19]

text: Prognosis[edit]

text:
Risk of death in untreated aortic dissection[citation needed]

25%
in first 24 hours

50%
in first 48 hours

75%
in first week

90%
in first month

text: Of all people with aortic dissection, 40% die immediately and do not reach a hospital in time. Of the remainder, 1% die every hour, making prompt diagnosis and treatment a priority. Even after diagnosis, 5–20% die during surgery or in the immediate postoperative period.[8] In ascending aortic dissection, if surgery is decided to be not appropriate, 75% die within 2 weeks. With aggressive treatment, 30-day survival for thoracic dissections may be as high as 90%.[20]

text: History[edit]

text: The earliest fully documented case of aortic dissection is attributed to Frank Nicholls in his autopsy report of King George II of Great Britain, who had been found dead on 25 October 1760; the report describes dissection of the aortic arch and into the pericardium.[3][21] The term "aortic dissection" was introduced by the French physician J.P. Maunoir in 1802, and René Laennec labelled the condition "dissecting aneurysm".[3][22] London cardiologist Thomas Bevill Peacock contributed to the understanding of the condition by publishing two series of the cases described in the literature so far: 19 cases in an 1843 review, and 80 in 1863.[22] The characteristic symptom of tearing pain in the chest was recognized in 1855 when a case was diagnosed in life.[22]

text: Surgery for aortic dissection was first introduced and developed by Michael E. DeBakey, Denton Cooley, and Oscar Creech, cardiac surgeons associated with the Baylor College of Medicine, Houston, Texas, in 1954. DeBakey developed aortic dissection himself at age 97 in 2005,[3] and underwent surgery in 2006.[23] Endovascular treatment of aortic dissection was developed in the 1990s.[3]

text: Society and culture[edit]

text: Ritter rules[edit]

text: Ritter rules are a compilation of reminders, symptoms, and risk factors designed to prevent the misdiagnosis of thoracic aortic dissection.[24] The rules were named for actor John Ritter, who died from a thoracic aortic dissection on September 11, 2003. Ritter was initially misdiagnosed and subsequently treated for a heart attack.[25] The Ritter rules were developed by Dianna Milewicz, of the University of Texas Medical School, Houston, and were jointly published in March 2010 by John Ritter Foundation and the Thoracic Aortic Disease Coalition.[24][25][26]