Esophagopleural fistula secondary to purulent empyema thoracis is an uncommon condition. Seventeen cases from the literature are reviewed here, in most of which the diagnosis was made when particles of ingested food appeared in material from the draining empyema cavity. The case to be recorded is the first in which the diagnosis of esophagopleural fistula was established by roentgen examination prior to any operative procedure. Report of Case2 A 4-year-old white girl was admitted to Alton Memorial Hospital, Oct. 10, 1944, because of diarrhea and vomiting of one week duration. She had been chronically ill during the past two years, but all treatment had been at home until the present admission. Two years earlier she had had an acute illness and the parents were told she had pneumonia followed by a lung abscess. She apparently recovered in about three weeks but since that time she had had an intermittent chronic cough and frequent colds. One year preceding admission, depression of the right chest was noticed, and this had become progressively more pronounced. The parents thought that during the three months prior to the present illness the child 's health had been better than at any other time in the past two years. During the past year, however, there had been a marked loss of weight and strength. One week before admission there was sudden vomiting of watery, greenish yellow material. Diarrhea and fever followed, and the patient became acutely ill. There was frequent cough, which often stimulated vomiting. General Examination: The patient was obviously ill. She was emaciated and extremely poorly developed. Her weight was only 19 pounds, and the body appeared to be that of a 2-year-old child. The right chest was flattened at the apex, there was pronounced scoliosis, and the anteroposterior diameter was greatly decreased on the right. There was no respiratory excursion. On the right, breath sounds were diminished; on the left, a few sticky râles were heard. The liver was palpable. The fingers showed early clubbing. Temperature on admission was 103° showed 3+ albumin and an occasional hyaline cast. There were 23,800 leukocytes, with 83 per cent neutrophils and 17 per cent lymphocytes. The erythrocyte count was 4,400,000, with 62 per cent hemoglobin. There was repeated vomiting of foul-smelling green fluid . At the Alton Memorial Hospital the patient was given supportive treatment only. Roentgen Examination: A postero-anterior view of the chest (Fig. 1), made the day after admission, revealed a complete opacity over most of the right side, with a fluid level in the mid-portion and air above the fluid. Pronounced lack of development of the right thorax indicated long duration of the condition. Traces of opaque material seen in the colon were assumed to be some opaque medicament. A faint trace of a substance of similar density was seen in the lower portion of the right chest.