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During the last fifteen years we have observed a number of patients in whom there was a pulsating vascular swelling at the right side of the root of the neck which at first sight suggested a carotid or innominate aneurysm. Subsequent investigation enabled aneurysm to be excluded and proved the vascular swelling to be a tortuosity or kinking near the origin of the right carotid. Often the pulsating tumour was the main or the sole complaint, and sometimes surgical treatment for aneurysm had been contemplated. HISTORICAL Coulson (1852) described a woman, aged 82, " who for some years before her death had a pulsating tumour, of the size of an orange, just above the right clavicle, in the situation of the carotid. The swelling had not of late increased in size and caused no inconvenience ; the woman died from natural decay. The vessels arising from the aorta were elongated and considerably dilated; and the tumour, which was considered before death to be aneurysmal, consisted of a reduplication of the right common carotid. The interior of the vessels was highly vascular and there was considerable atheromatous deposit." Hulke (1893) described a case like that of Coulson's, but without necropsy. She had " a conspicuous pulsating swelling which projected the sterno-mastoid muscle" and was thought to be an aneurysm of the common carotid artery. He concluded that the swelling was formed by a long loop of the carotid artery, comparable with the tortuosities found in more superficial arteries. Douglas Powell (1909) reported upon a female, aged 78, with a pulsating tumour presenting the character of an aneurysm about the size of a walnut. It was defined as a widened, bent, and slightly twisted carotid artery. It proved to be a high division of the innominate artery, with a twisted kinked [sic] condition of the carotid, the walls of which were atheromatous and partially calcareous. At necropsy, " The right carotid was tortuous and considerably displaced. It was twisted to the right, forming a marked curve, about onethird of a circle; it also showed antero-posterior deviation as well. The right 345

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