Notching of Ribs Without Coarctation

Notching of the ribs by dilated and tortuous intercostal arteries, visible by x-ray, as a sign of coarctation of the aorta, was first described in 1928 by Roesler (2) (then of Vienna, now of Temple University, Philadelphia). The first notice in regard to the roentgenographic appearance in English was given by Railsback and Dock (1), in 1929, who found descriptions of notching in articles written long before the discovery of the x-ray. They noted the absence of mention of the appearance in several x-ray texts but were apparently unaware of the independent work by Roesler, which had appeared in the previous year in the German literature. Since that time several articles on coarctation have appeared in medical journals and in textbooks, all of them calling attention to the notching of the ribs, which, if present, was thought to be practically (italics are the authors') pathognomonic of coarctation. In Roesler's (3) book on roentgenology of the heart, for example, he says (p. 398): “The erosion of the ribs is the most unequivocal roentgenographic sign…. These erosions are multiple, bilateral and limited to the caudal margins of the dorsal portions of the ribs. They are limited to the right hemithorax when the seat of coarctation is proximal to the origin of the left subclavian artery.” We have observed a patient with notching of the left ribs only, without coarctation of the aorta. Case History A 38-year-old, single, white male was admitted to the Rhode Island Hospital with dyspnea, orthopnea, and cyanosis. He had been known to have “heart trouble” since the age of six, and activity had been restricted because exercise brought on dyspnea and cyanosis. With care, he had done quite well until about two months previously, when he began to have headaches, loss of appetite, nocturnal dyspnea, and orthopnea. He coughed some, but had no edema or ascites. There was no history of rheumatic fever. Physical examination showed cyanosis and rapid respirations, with dullness at both lung bases. The heart showed a rapid regular rate, increased width to percussion, and a thrill over the apex. No murmurs were present, and the sounds were loud and snapping. The blood pressure in the right and left arms was 110/90 and in the left leg was 145/110. The liver descended about one finger breadth below the costal margin on deep inspiration. The circulation time was delayed according to several tests. The Wassermann and Hinton reactions were reported negative. The blood showed hemoglobin 112 per cent, red cells 4,960,000, white cells 3,200. X-ray examination revealed a very large heart shadow, engorged blood vessels, and notching of the under edges of the left 5th, 6th, and 7th ribs. The patient failed rapidly and died with signs of cardiac failure and terminal pneumonia seven days after admission. The autopsy findings pertinent to this report follow. Autopsy Report Autopsy was performed two hours after death.