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Shortness of breath and slight mediastinal shift are not uncommon in the presence of a large pleural effusion. It is not generally recognized, however, that in certain circumstances pleural fluid may accumulate under such greatly increased pressure that it results in gross mediastinal shift and irreversible respiratory and circulatory changes. The following is a report of such a case of fatal 'tension hydrothorax'. CASE REPORT C.A., a 43-year-old woman, suffered increasingly severe dyspnoea, weakness, and right chest pain for two months.The physical findings included marked shortness of breath with a respiratory rate of 40/min., pulse 120/min., evidence of a large right pleural effusion, and a temperature of 103' F. A blood serum protein determination showed albumin 1.4 g./ 100 ml. and globulin 4-7 g./ 100 ml.A chest radiograph (Fig. 1) showed a large right pleural effusion. The mediastinum was in the midline. It had previously been displaced slightly to the left, but this was corrected on several occasions by thoracentesis, which revealed non-diagnostic serosanguineous fluid. Bronchoscopy, scalene node biopsy, and needle biopsy of the pleura were negative. Later attempts at thoracentesis failed and dyspnoea increased with a respiratory rate as high as 56/minute. During a radiological examination done in the supine position the patient suddenly became unresponsive, and pulse and blood pressure could not be obtained. Because of the gross displacement of the heart and mediastinum to the left (Fig. 2)

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