C. THE TENDENCY TO ORGANIZATION OF BRONCHIOLAR AND ALVEOLAR EXUDATES
The sequelæ after exposure to gas may be markedly delayed. They occur, not only in animals which have exhibited characteristic acute symptoms, but also, and especially with phosgene, where no serious immediate clinical effects followed exposure to the gases. They are dependent upon the fact that the pneumonic process has a very striking tendency to undergo organization, a process which involves not only the exudate in the alveoli, but also that within the bronchioles. The organizing process may be present in both these portions of the lung or may be confined to the bronchiole alone, and lead to a progressive interference with the ingress and egress of alveolar air, so that atelectasis and emphysema become permanent, and in turn lead to narrowing of the vascular bed, ultimately producing right-sided cardiac decompensation. Bronchiectases also occur; they may be tubular, associated with organization of the pneumonic process in their vicinity, or saccular if death has not followed the destruction of the bronchiolar wall.
Compare this picture with that of influenzal pneumonia and its sequelæ; in both there is, first the acute diffuse involvement of the lung, initiated by, or occurring simultaneously with, an acute tracheobronchitis and presenting clinically dyspnœa, cyanosis, blood-stained, abundant sputum, and even interstitial emphysema; next, the tendency for the pneumonic process to localize and to necrotize; and finally, if the acute period is survived, organization of the pneumonic and bronchiolar exudates with resulting bronchiolitis and bronchiectasis. With even more minute comparison, the resemblance is sustained. The initial or early dilatation of the ducti alveolares, so characteristic in gas poisoning, also occupies the foreground of the histological picture in influenza. These dilated structures are the more prominent on account of the red, ribbon-like strands that cover the surface and often involve the walls. Similar necrotization, varying in its depth even to involve the whole of the alveolar walls, occurs in both of these conditions. Similar hemorrhages in the early stage, rupture of the alveolar wall with interstitial and subcutaneous emphysema, necrotization, gangrene, and organization in the same localities, characterize the two lesions, and are not found with the same uniformity in any other type of respiratory disease.