Demonstrable interpleural communications in man are notably uncommon. The anatomic basis of such natural and spontaneous phenomena is not clear. However, the basis for possible rupture or mechanical break does exist in the anatomic structure of the mediastinum. This has been studied in some detail by Nitsch,1 who described two "weak" places in the structure of the mediastinum—one posterior to the upper portion of the sternum at the level of the second, third and fourth ribs, and the second in the posterior inferior portion of the mediastinum near the level of the eighth rib. When there is a pneumothorax with high pressure or when a pleural exudate is present, the mediastinum in the latter region may bulge to the opposite side, suggesting hernia. In the presence of pneumothorax with excessive pressure, particularly if adhesions are present, the possibility of a pleural tear in either of the weak places must
Smith CR, Willis HS. COMMUNICATION BETWEEN THE TWO PLEURAL SACS, WITH LUNGS SHOWING TUBERCULOSIS HEALED AFTER THORACOPLASTY. JAMA. 1933;101(16):1224–1226. doi:10.1001/jama.1933.27430410001007
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