The purpose of this paper is to discuss briefly one of medicine's catastrophic conditions; namely, post-emetic rupture of the esophagus, a rather uncommon accident, but by no means a rarity. Although the history, clinical, and roentgen findings are characteristic, the diagnosis is frequently missed and the condition terminates fatally. Prompt surgical treatment is necessary if the patient is to survive. This condition, sometimes spoken of as spontaneous rupture of the esophagus, is to be differentiated from perforation secondary to intrinsic or extrinsic disease, as well as from traumatic rupture of the esophagus from intrinsic or extrinsic causes or agents. By definition, post-emetic rupture of the esophagus is a tear through all layers of the wall of a normal esophagus as a result of vomiting. The 3 cases to be presented here, seen during the past two and one-half years, have all ended fatally. Spontaneous rupture of the esophagus was first described by Boerhaave in 1724. His patient was the Grand Admiral of the Netherlands Navy, and the rupture occurred as a result of vomiting and retching following ingestion of large quantities of food and alcoholic beverages. Until the 1940's, the disease was almost invariably fatal. The first successful surgical treatment was performed in 1946. The reported cases have been predominantly in males, by a ratio of 5 to 1. The average age is forty-five to fifty years. The history often reveals overindulgence in eating and/or drinking followed by vomiting and the sudden onset of severe pain in the epigastric or substernal area. The patient becomes critically ill and the course is rapidly downhill. Physical findings will vary depending on the time elapsed following the rupture. Generally the patient is suffering from extreme chest or upper abdominal pain and is restless, dyspneic, and cyanotic. Often there is a nasal twang to the voice. Subcutaneous emphysema may be present in the soft tissues of the upper chest and neck. There may be evidence of hydropneumo-thorax either unilaterally or bilaterally. Upper abdominal rigidity may be present. It is again emphasized that the course is rapidly downhill. Sooner or later the patient goes into shock due to pain, contamination, and anoxia. The possibility of esophageal rupture must be kept in mind if an early diagnosis is to be made. Among the conditions to be differentiated are perforated peptic ulcer, acute pancreatitis, empyema of the gallbladder, acute coronary occlusion, pulmonary embolism, and spontaneous pneumothorax. The most commonly confused condition is ruptured peptic ulcer. Many patients operated upon with this diagnosis in mind have been found to have no abdominal lesion. The rupture is generally considered to be the result of increased intraluminal pressure, due to spasm of the pyloric and crico-pharyngeus muscles with associated vomiting and retching.