A 50-year-old salesman is on a yacht with a client when he has a severe vomiting and retching spell punctuated by a sharp substernal pain. He arrives in your emergency room 4 h later and has a chest film in which the left descending aorta is outlined by air density. Optimum strategy for care would be - a- Immediate thoracotomy b- Serial ECGs and CPKs to rule out myocardial ischemia c- Left chest tube and spit fistula (cervical esophagostomy) d- Flexible esophagogastroscopy to establish diagnosis e- Nasogastric tube, antibiotics, and close monitoring Answer: a. (Henderson, Am J Med 86:559-567, 1989) The presence of air in the mediastinum after an episode of vomiting and retching is virtually pathognomonic of spontaneous rupture of the esophagus (Boerhaave syndrome). The evidence is overwhelming that without prompt surgical exploration of the mediastinum by left thoracotomy, the patient has little chance for a short-term outcome of low morbidity. The aspiration of highly acidic gastric contents in to the mediastinum creates havoc in the tissues exposed to it. The surgical procedure must include extensive opening of the mediastinal pleura and removal f any particulate debris that might have been aspirated in to the thorax from the stomach. Closure of the esophageal laceration with reinforcement by a pleural flap and secure chest tube draining of the pleural space are mandatory. If the operation is delayed beyond the first 8 to 24 h, the mortality rises sharply and survival will only follow prolonged intensive care and multiple operations. This catastrophic event is one of the few in which prompt diagnosis and intervention are crucial to success. Because the findings are classic and the diagnosis is so important, Boerhaave syndrome justifiably receives emphasis in educational programs for emergency physicians, internists, radiologists, and surgeons alike.