What triggered the fire in or near the radiological film storage area was not clear initially, but further research indicated that the room in which old films were stored in manila envelopes was located on the west side of the basement near an elevator shaft. A leak in a high-pressure steam line had developed in the room that morning, soaking the stored film. A steam-fitter, Buffery Boggs of the Rhoton Company, was called. He removed about 14 inches of insulation that allowed a jet of steam to pour from the pipe, about eight inches from the file storage shelf. He then went to the powerhouse to close the steam line.

“Upon returning to the film room about 11 a.m., the workman discovered a cloud of yellow smoke in one upper corner of the room,” wrote John D. Clough, M.D., editor of the History of the Cleveland Clinic. “He emptied a fire extinguisher in the direction of the smoke, but was soon overcome by the fumes and fell to the floor. Revived by a draft of fresh air, he crawled toward the door on hands and knees. A small explosion flung him through the doorway into a maintenance room, where another workman joined him. Together they made their way through a window and out of the building.”

The gas then ignited in a second explosion, the blast shooting poisonous gas through the X-ray labs, out into the hallways, and up ventilator shafts and staircases. Around 250 people were in the hospital at the time. Some later compared it to the gas attacks of World War One, and victims – physicians, technicians, nurses, aides, patients, and visitors – fell wherever they were, quickly asphyxiated by the mixture of deadly gases. “Gasping for breath, waging a frantic battle to reach fresh air, men and women, trapped in the building, dropped in the halls to expire, unable to escape the deadly fumes,” reported the New York Times on Thursday, May 16, 1929.

The explosion shook the building, sending staff and ambulatory patients rushing to the exits, but many failed to make it in time. In the blast, “the building rocked, glass burst from the windows, the skylight fell in, plaster collapsed, and the clinic became a charnel house.” Firemen “found bodies packed deep in the space between the elevator and the stairway,” according to the Times.

Several firemen came to the rescue through skylights or trapdoors to the roof in an attempt to rescue victims. “Other [victims], some unclothed or partly disrobed, were crushed beneath falling debris, heavy diagnostic apparatus, or operating tables,” the Times report continued. “Physicians, chemists, and nurses fell with instruments, test tubes, and charts in their hands. Death halted them as they gave relief from pain. As the yellow colored smoke rolled out the doors and windows of the clinic, the screams and yells of the trapped patients could be heard for blocks.”

The Times quoted fireman Louis Hildebrand, who had sought access from a skylight: “Lord help me, as far down the stairway as you could see were bodies, bodies, bodies. Twisted arms and legs, screaming men and women. Bodies and screams.”

Many were jammed together in an attempt to reach the roof. “It took three firemen to force a way down the stairway and to lift the top one to men on the roof,” said Battalion Chief Michael Graham. “For five minutes we were lifting those bodies to the skylight before we could get to the third floor, where the screaming was the worst.” One policeman, Ernest Stabb, who had arrived early, helped remove victims until he, too, expired.

Rescue work and emergency care (administration of oxygen to overcome the gas burns to the lungs) was directed by Crile. Crile even donated blood in an attempt to save one of the founding physicians, John Philips, who had rushed from his suburban home with extra oxygen tanks to help save victims, only to become a victim himself. It was hours after the explosion before all the victims could be removed from the building and placed in a temporary morgue for identification.

“The courageous spirit of the remaining [clinic] founders and their associates did not fail, and a far greater institution was to [continue to] serve humanity,” wrote William Ganson Rose in Cleveland: The Making of a City (World Publishing, 1950).

A Common Killer

Experts initially debated what gas had caused the deaths. Some chemists thought it had been bromide fumes, but the nitrocellulose X-ray film appeared to be the source of the deadly gases, according to Louis Van Oeyen of the Cleveland Press, who arrived to photograph the scene while the rescues were continuing.

In his book, They Died Crawling, John Stark Bellamy II, a history specialist with the Cleveland Public Library, quoted Torald Sollmann of the Western Reserve School of Medicine (now Case Western Reserve): “In some way not known, the gas gets fixed in the thin walls of the lungs. The resulting irritation makes these cells soluble and as a result the watery part of the blood stream begins to leak through them into the lungs. The lungs fill with water, drowning the patient.”

The New York Times reported on that city's own potential for a similar type of loss. “Fire underwriters impose stringent regulations, but find enforcement hard,” the paper noted. “While fire underwriters here last night urged legislation compelling the replacement of nitro-cellulose X-ray films … with safety (acetate cellulose) films for all X-ray work, New York Fire Department officials insisted upon the extreme unlikelihood of such an occurrence in this city.”

New York medical and fire officials believed, the article continued, “that the explosions were caused by the ignition of inflammable nitrocellulose film, perhaps in combination with various substances used in the emulsion on the film,” releasing a bromide similar to that used in gas warfare. The chemical gas, cellulose nitrate (occasionally referred to as pyroxylin), is made by the action of nitric and sulfuric acids on cellulose material such as cotton, forming a plastic-like substance.

“Cellulose nitrate plastics possess the most unusual and serious burning characteristics of all plastics,” according to the National Fire Protection Association's Fire Protection Handbook (15th Ed.). “Material which has been subjected to heat, such as that salvaged from a fire, may be so altered in composition that it is subject to spontaneous ignition.

“When cellulose nitrate products are heated to temperatures above 300? F, decomposition starts, which generates further heat and soon raises the material to its ignition temperature,” the handbook continued. “Some of the gases produced by decomposition are highly toxic. The effect of carbon monoxide is well known. The toxic effect of the oxides of nitrogen is often delayed; persons exposed to these gases may show no immediate ill effects, but fatalities may follow some hours or days after exposure.” The NFPA stated that all photographic film made in the U.S. and Canada since 1952 is a safer variety, usually cellulose acetate or triacetate or polyester, however, some engraving plants still use cellulose nitrate plates.

The gases produced in a fire often are more deadly than the flames. It is not known how many of the 123 fatalities (William G. Rose, who was affiliated with the Cleveland Plain Dealer, says 124) and 50 injured in the Cleveland Clinic loss were killed or injured by either the blast or the flames, rather than by the poisonous gases, but it is likely from the descriptions of the rescuers that the gas was a greater killer.

Handling Claims

To what extent victims or their families collected benefits for their injuries or loved ones is not clear. Clough, in his History of the Cleveland Clinic, said, “Liability insurance coverage for such carnage was inadequate, but it did provide $8,000 per person, plus funeral or hospital expenses.” Clough confirmed that immunities applicable to eleemosynary institutions and hospitals in 1929 barred some of the litigation one might expect from such a tragedy today. “The founders,” he says, “suffered no personal liability because the foundation, which owned everything, was a nonprofit corporation of which the founders were salaried employees.”

The state of Ohio abolished its charitable immunity doctrine in 1985 in Albritton v. Neighborhood Centers Assn. for Child Development (466 N.E.2d 867), in which the court said:

The rule has been devoured by exceptions: immunity for hospitals has been abolished; where the injured party is not a beneficiary of the charity or pays for the services rendered; or where the charity operates a business enterprise for profit. The very existence of these exceptions militates strongly against all of the policy arguments in favor of the doctrine. There is no compelling precedential reason for its retention.

Although the Cleveland Clinic may have been a charitable institution at the time (this writer was a patient there briefly in 1953), only patients and visitors would have had a right of claim other than for workers' compensation.

Ohio had enacted workers' compensation statutes in 1911 and earlier, and as a fund state, the state itself would have handled any claims of employees. Clough commented, “State industrial insurance gave what [the director, Crile] termed 'cold comfort' to the personnel. The medical staff, however, took on the task of paying the families of the members of the staff who had died full salary for the first six months and half salary for the next six.”

The clinic building also suffered significant damage in the explosion. While it still stands in its original 1921 structure, with numerous additions, Clough reported that it was rendered temporarily unusable. “The interior was badly damaged, brownish stains were present everywhere, and there was a rumor that lethal fumes were still escaping. Some advised razing the building, fearing that patients would never again be willing to enter it. [Founding physicians] Lower and Crile, however, adopted a wise position. 'They'll talk for a while,' Crile said, 'and then, when they forget it, we'll start again to use the building.' That is exactly what happened.” Meanwhile, a house across the street was used as a temporary clinic, and some activities were transferred to a nearby school.

Hospitals and Gases

Hospitals continue to be hazardous places. “In hospitals … where flammable [oxygen or] anesthetics are or may be administered to patients, … special rules apply,” the NFPA stated. “The NEC (code) defines the anesthetizing (hazardous) areas as any area in which it is intended to administer any flammable inhalation agent. It includes operating rooms, delivery rooms, emergency rooms, and the anesthetizing rooms, and other areas when used for induction of anesthesia with flammable anesthetizing agents.”

Anesthetics are not the only hazardous materials in a hospital, however. Numerous cases of liability have been reported as resulting from the mishandling of nuclear materials used in various medical procedures. In one infamous case, nuclear waste somehow leaked into the bed of a truck, which later was used as scrap metal, ending up in a product in Mexico, where the product was found to be radioactive and harmful to purchasers.

The propensities of poisonous gases (beyond those used on battlefields or for prison executions) also has created a medium for terrorists. An example is the exposure of thousands to the poisonous cyanide gas in the Tokyo subway attack in 1995. “One byproduct of fire is smoke,” wrote Gary Ludwig, a chief paramedic in St. Louis, Mo., in the June, 2004, issue of Firehouse (“New Thinking About Treating Smoke Inhalation Victims”). “Smoke contains particulate matter and heated gases such as hydrochloric acid, sulfur dioxide, ammonia and carbon dioxide, and toxins, including hydrogen sulfide and hydrogen cyanide.” Ludwig cited the history of cyanide as a killer, used in the 1982 Tylenol tampering case, which left seven dead, and other fatal product tampering cases, and the genocide by the Nazis, who used Zyklon B in their death chambers.

“Terrorists also like cyanide,” he continued. “It has been speculated that terrorists placed cyanide in the truck used in the bombing of the World Trade Center in 1993, but it incinerated with the explosion.” He noted that it also was used in terrorist plots in 2002 and 2003 in London, Rome, and Texas.

Whether the poisonous gas is the result of an industrial or building fire, a terrorist act, or a natural phenomenon (volcanic eruptions often contain poisonous gases, for example), the results will be a large number of fatalities and injuries, and hundreds, if not thousands, of claims, both in workers' compensation and tort. Assessing the exposure is the role of risk managers who may, unwittingly, be sitting on top of a hazard such as those X-ray films in Cleveland in 1929. Major losses often occur because those who are around such hazards begin to feel comfortable with the risk and fail to recognize how quickly some minor incident can become a disaster. For those who insure such risks, or those in entities that self-fund risks, the vigilance must be immediate and ongoing.