Multilamellated structures (MS), which accumulate in the lungs of patients with pulmonary alveolar proteinosis, were examined under the electron microscope. MS, in general, consisted of alternating light and dark lamellae arranged concentrically about membranous vesicles or electron-dense bodies. The darker osmiophilic lamellae consisted of trilaminar membranes 80 to 100 A thick, and the lighter lamellae, which varied from 150 to 300 A in width, appeared amorphous. MS made up 42.6 +/- 12.4% (n = 4) of the total particulate volume present in the pulmonary lavage effluents. MS resembled tubular myelin structures from the lungs of patients, although these latter structures accounted for only 1.6 +/- 2.3% (n = 4) of the total particulate volume. Abnormalities, such as polygonal tubules, irregular tubule dimensions, and large size potential, indicated that tubular myelin structures in the lungs of patients were variable in structure. MS appear to be a form of tubular myelin structure. MS were treated with a variety of disruptive agents and then examined under the electron microscope. Information was obtained about the composition of the MS and the intermolecular forces involved in their three-dimensional organization. Extraction of the MS with acetone or treatment of the structures with phospholipase c resulted in loss of membranes from the structures without a concomitant loss of the intermembranous amorphous material, indicating that phospholipids were a major membrane component. Analysis of phospholipids in the acetone extracts of the MS revealed that the membranes consisted of 45% phosphatidylcholine and that the major fatty acid of the phosphatidylcholine was palmitate (76%). The amorphous material of the intermembranous spaces consisted primarily of protein, since it was destroyed by the proteases trypsin and pronase without loss of the membranes. Reducing agents such as mercaptoethanol and dithiothreitol were disruptive, indicating the importance of disulfide bridges between the protein constituents in maintaining the integrity of the MS. The significance of hydrophobic interactions between the protein constituents was demonstrated by the disruptive action of chaotropic agents according to the sequence KSCN greater than KI greater than KCl. These data indicate that MS consist of phospholipid membranes organized in a protein matrix maintained by intermolecular disulfide bridges and hydrophobic interactions.