Medical thoracoscopy (MT) provides the physician a window into the pleural space. The procedure allows biopsy of the parietal pleura under direct visualization with good accuracy. In addition, it facilitates therapeutic interventions such as fluid drainage, guided chest tube placement, and pleurodesis. Thoracoscopy as described by Jacobaeus in 1910 was a technique to collapse the underlying lung infected by tuberculous mycobacteria. Thoracoscopy fell into oblivion in the 1960s due to effective antituberculous drugs and enjoyed a resurgence when thoracic surgeons introduced it for minimally invasive surgery also known as video-assisted thoracoscopic surgery (VATS). VATS is performed under general anesthesia with double lumen endotracheal intubation and single lung ventilation, while medical thoracoscopy (MT) is performed by the pulmonologist in an endoscopy suite using rigid or flex-rigid instruments under local anesthesia and moderate sedation and with the patients spontaneously breathing. MT is less invasive, and comparable diagnostic yield is achieved with the flex-rigid instrument compared with VATS. MT using the flex-rigid pleuroscope is extremely well tolerated under local anesthesia and can be safely performed as an outpatient procedure. Biopsy quality can be enhanced with accessories that are compatible with the flex-rigid pleuroscope such as the insulated tip knife and cryoprobe. In the era of sensitive imaging tools, image-guided pleural biopsy, and advances in cytopathology, MT continues to play a pivotal role in the expeditious evaluation of patients with pleuropulmonary diseases.