UNIT IV

2 0 TiMELLNE

OF DEATH Cleveland Clinic Disaster

ANY OHIO DISASTERS have announced themselves with a bang. The 1944 East Ohio Gas Company fire hegan with

I a blast heard fourteen miles away. Y The 1916 Cleveland Waterworks

explosion likewise made impressive noise, as did the 1908 S. S. Kresge tragedy, which commenced with literally deafening fireworks.

Not so with the calamity that hefell the Cleveland Clinic. It came, initially invisible and unrecognized, through the ductwork and pipe conduits of the clinic building. It first accosted its victims as powdery flecks and puffs of smoke emanating from heating vents and registers. And many of its casualties may already have been dead when the first blast came at about 11:25 A.M.. May 15, 1929.

Then, as now, the clinic was one of Cleveland's great success stories. Founded in 1921, it was the joint inspira- tion of Doctors George W. Crile, Frank E. Bunts, and William E. Lowther. Galvanized by their service together in Cleveland's Lakeside Unit during World War I, the trio had decided to put the model of team medical practice developed in France to peacetime use. Joining with Dr. John Phillips and drawing on the example of the Mayo Clinic, the doctors, in only eight years, had created a cutting-edge treatment center. Already world renowned, the clinic annually welcomed thousands of patients who came to find comfort and cure within its walls.

July August 2002 21

THE CLINIC BUILDIMG, CLEVELAND. OHCO. M

The Cleveland Clinic was a ¡oint venture by a group of physicians to provide medical services incorporating the latest in specialized research while also providing a setting for postgraduate education. The four-story main building was completed on the southwest corner of East Ninety-third Street and Euclid Avenue in 1921. deveiand Clinic Archives

Even in 1929, the clinic was physically impressive. Located just west of East Ninety-third Street on the south side of Euclid Avenue, the four-huilding complex included a 184-bed hospital and a research building used for special laboratories, such as radioîogy. The main building was a four-story structure of reinforced concrete and brick. It housed both administrative offices and rooms used for consultation and outpatient procedures.

Considered "fireproof" when built in 1920, the main building's primary activities occurred in dozens of examining and consulting rooms on the upper three floors. An interior court rose from the second-fioor waiting room up to a thirty-hy-thirtj'-eight-foot skylight. Two elevators and two staircases provided access to the upper fioors whose mezzanine-style balconies flanked the interior court.

Like most buildings of the era, the clinic building's environ- mental infrastructure deployed from a central basement location. Encompassing about one-third the square footage of the 75- by 124-foot building, the hasement housed unused steam boilers (rendered redundant by the complex's new central heating plant), fans for the ventilation system, and storage rooms for files, supplies, and drugs. Fataiiy, it also contained a storage room for x-ray films.

22 TIMELINE

Clinic chief Dr. George W. Crile subsequently would insist that there was "no precedent" for the clinic tragedy. That was not quite true, whether he knew it or not. In September 1923, gases generated by burning x-ray film and dispersed through a ventilating system had overwhelmed victims at a Syracuse hospital. And, in March 1928, eight

persons in an Albany hospital had heen killed by fumes from burning x-rays.

The villain in botb disasters was nitro- cellulose x-ray film. The actual x-ray image, composed of silver pariicles suspended in a gelatin layer, was not a problem. The film's transparent base was. It was made of nitro- cellulose, a polymer derived from organic cellulose. While fiexihle and clear, it couid

ignite at oniy thi-ee hundred degrees Fahrenheit and could b u m without an

independent source of oxygen. Indeed, the film was unstable and could decom- pose if improperly stored, making it even more dangerous. Eastman Kodak had placed the film on the market in

Raised on a farm in Coshocton County, Dr. George Washington Crile was the drtving force behind the clinic. He had a lifelong, consuming obsession with research and worked diligently to improve the practice of surgery in the nation. He was a pioneer in the diagnosis and treatment of shock and a skilled surgeon of the head and neok. Cieveland Clinic Archives

the century's second decade and soon realized its potential danger. The company introduced acetate- base "safety" film in the mid-1920s but continued to market the nitrate-base x-ray film until 1933. Witbout question, Kodak's conversion to safety film was accelerated by the clinic disaster.

Given its letbal contents, the clinic's basement storage room was dangerous enough. The room contained some seventy thousand x-ray sheets, at least 4,200 pounds of film. Each pound was capable of producing between three and six cubic feet o£ toxic gases. Several factors — most in \iolation of American Hospital Association guidelines — made the situation even more perilous. Unhke those in many other medical facilities, some Cleveland Clinic x-rays were not stored in metal containers. Although some were stored in metal filing cabinets, many films were filed on open wooden racks, and aU were filed in flammable paper or manila jackets. Unlike many other large medical facilities, the clinic had no fire-sprinkling system in the storage room or anywhere else in the building. And, going against an increasingly common practice in American hospitals, x-ray films were not stored in an area isolated from patient areas. Wor.st of all, the clinic building's ventilation apparatus was also located near the x-ray storage room.

Like most terrible disasters, the clinic tragedy was the cumulative product of mundane and indi- vidually innocuous circumstances. In early 1929, Miss Enid Critcher asked chief custodian Waiter Adams to do something about the lighting in the x-ray storage room. Although the room was lit by four one-hundred-watt drop fixtures, Critcber found it difficult to see while filing films. Adams responded by putting a Y double-outlet at the end of one of the drop fixtures. Such an outlet could ser^iice either

Dr. John Phiiiips, a facuity member at Western Reserve University, joined the ciinio staff shortiy after its establishment. Born and trained in Canada, the internist was widely respected for his teaching abilities and for his knowiedge of children's dis- eases. Cieveiand Ciinic Archives

two one-hundred-watt bulbs or one bulb and an electrical outlet. Adams would later deny any knowledge of an eight-foot extension cord that was hooked up to a female end of that Y fixture. Or, as Miss Critcher testified, that it was connected to a o ne-hundred-watt bulb, which was looped over a "big spike" and hung down near the film cabinets.

Nitroceiiuiose-base x-ray fiims, stored in the northwest corner of the basement in both steel cabinets and on open shelving, first fueied the fire. Investigation initialiy focused on the steel tire door between the tile room and the adjaoent boiier room. A heat-activated mechanism designed to automaticaliy close the door in the event of fire had malfunctioned. OiBveiand State University, Cieveiand Press Coiiection

July * August 2002 23

The clinic's reception room was on the second fioor. two stories below the sky light, Cieveiand State University, Cieveiand Press Collection

A steamfitter with the unlikely name of Buffery Boggs played a key roie in the disaster Cleveland Clinic Archives

There was no inkling of the woe to come when a man with the improbably Dickensian name of Buffery Boggs arrived at the main clinic building about 9 A.M. on May 15, A steamfitter's helper employed by the W, R, Rhoton Company, Boggs had come to repair a leaking pipe in the x-ray storage room. Moisture had already damaged some films, which had been removed and placed on top of the filing cabinets to prevent further damage.

Eoggs quickly located the leak. But the pipe was too hot for patching work, so he requested that the steam be shut oft, lie then lefi the building. Before he departed, however, he noLiced the improvised lighting that custodian Adams later disclaimed: "Just a common everyday light bulb dropped down on an extension cord from the ceiling,"

This article is adapted from They Died Crawling© 1995 by John Stark Beliamy li. It is printed here with permis- sion of Gray and Company, Publishers.

Did Boggs smoke a cigarette or two while he was working at that pipe? Investigators later focused on the possibility that film ignition had been triggered by a cigarette left by Boggs in the x-ray room. But their persistent probing of his smoking habits would seem to be a gratuitous slur, as no evidence was ever produced to indicate that Boggs smoked in tbe storage room on May 15,

Boggs returned to his leaky pipe after 11 A.M. As he walked through the door to the x-ray room, he heard a "hissing sound." Although he did not smell any odor, he noticed that "the room was warm, it was dam warm." Then he saw "thick, yellowish smoke" coming from somewhere near the north wall. Boggs ran out of the room and yelled to chnic maintenance worker Sam Steel for a fire extinguisher, "There's a ñre in that room!" Steel handed Boggs a soda-acid extinguisher, and the agitated steamfitter hcgan to spray water on the spreading cloud of yellowish-brown smoke.

It didn't help. Just as he emptied the extinguisher, Boggs was overcome by smoke and fell to the fioor. "It stopped my breath," he recalled, "just as you would shut off a valve." Coming to, he crawled toward the open door. As he reached it, a "gigantic force" picked him up and blew him through the door and across tbe fioor on his stomach into a machine room, Boggs related that "it was as if a million cushions hit you at once."

Buffery Boggs's "gigantic force" was the disaster's first explosion, and it came about 11:25 A.M. Any- where from 250 to 330 people were in the building — and most of the 129 dead may already have been well on the way to tbe grave even before the first blast came. Decomposition (Bameless combustion}, or

24 TIMELINE

"cooking," of the x-ray ñlms in the basement storage room, caused by heat, had apparentiy been going on for some time. By the moment of tbe initial explosion at 11:25 A.M., lethal gases had thoroughly penetrated both the piping chases and ventilation system of tbe building right up to tbe roof. Bromine, nitrogen dioxide, carbon monoxide, nitrous oxide, nitrogen peroxide, hydrocyanic gas, hydrogen, and oxygen gases were being forced tbroughout all four floors as fast as tbe ventilation ducts and piping chases could carry tbem. The first blast probably came wben just enougb of tbe free bydrogen in tbe walls came into contact with a convenient spark.

The first hints in the clinic proper that something was amiss came when some employees and patients, especially women, noted a peculiar, unpleasant odor in the air, Herbert W, Decker, clinic pharmacist, was on the ground floor wben he sensed tbe foul smell and found a group of nurses gathered by its apparent source in a register. Dorothy Hyde, a typist in the pharmacy, noticed nothing until "some fine powder, plaster or something" began falling on her work. About tbe same time, Mrs. H. A, Brooks saw yellow dust coming out of a bole in the wall, and employee Maude Lehman noticed a pufi" of smoke coming out of the wall. Sbe had just told a staft doctor about it when the first blast shook the build- ing, and choking clouds of dirty, yellow-brown smoke enveloped all four floors.

All of what went on in tbe clinic building during the next twenty minutes is known only to God. Patterns of deatb, injury, and escape in the clinic tragedy would later be pieced together, but everything was just a maddened, incomprehensible chaos as at least 250 persons frantically sought to escape suffo- cating death. So lethal were the gases, especially the nitrogen peroxide and carbon monoxide, that most of tbe victims probably died within minutes of the first blast, if not before. Patients died without a sound on examination tables. Doctors suddenly fell to tbe fioor, scalpels still in hand. Battalion Fire Chief Michael Graham later described a corpse he found sitting in tbe second-floor lobby: "He looked as if be had just started to take a nap wben the fumes began." Others died screaming and crawling on the floors and windowsills, gasping for air.

It was a particularly gruesome death, as many eyewitnesses would testify. Altbough the exact chemical components and proportions of the lethal gases were never determined, large amounts of carbon monoxide and acidic nitrogen compounds certainly were present. Dr. Torald Sollmann, dean of the Western Reserve Scbool of Medicine, described their devastating effects chnically: "tbe gas gets fixed in tbe tbin walls of tbe lungs. The resulting irritation makes these cells soluble, and as a result the watery part of the blood stream begins to leak

Two sign painters were among the lirst rescuers on the scene. Running from an adjacent job siîe, fhey threw their ropes up to desperate people hangirtg out the windows. Later they retrieved their ladders and began hauling out victims. Cleveland Public Library. Photograph Collection

through tbem into the lungs. The lungs fill with water, drowning tbe patient." Some witnesses remembered tbat the faces of the corpses appeared yellow, blue, and green. A more-graphic description came fi"om Dr. William G. Epstein, who had brought his wife, Florence, to the clinic. He was in anotber building wben tbe first blast came and ran next door to find bis wife: "It was too horrible to describe.... That gas is awful stuff. It bites into the skin like acid — worse than acid. Because acid at least is local- ized. This gas eats into the tissues — and eats and eats and eats!...Her mouth was bleeding — ber eyes and nose virere bleeding. She couldn't speak." Florence Epstein died in her husband's arms. Dr. Howard Karsner of the Western Reser\'e Medical School stated that he bad never, in a career of twenty thousand autopsies, .seen conditions identical to those of clinic gas victims.

July • August 2002 25

The situation was worst on the upper fioors. Most of the people caught in the building were in tbe dozens of examining and diagnostic rooms on those floors, and the poison gas and explosion caught some patients in various stages of undress. Virtually every doctor and nurse behaved heroically and began trying to take patients on tbese floors to safety. Unfortunately, most patients were strangers to tbe clinic, and their quest for safety took them to the most obvious locations, the stairways and elevators. This only increased their peril and panic, as fires were already raging at blowtorcb beat in the

rear elevator well and stairway. Tbe toxic gases, moreover, were concentrating in the interior court, meaning that patients were safer staying in tbe side rooms and awaiting rescue via tbe windows.

Few patients involved in tbe escalating disaster knew tbat. Tbat is why most of tbe victims were later found stacked, sometimes a dozen or more together, in piles by the staircases and tbe second- and third-floor elevator doors. So frantic was the press of escapees by tbe third-fioor elevator that its metal doors were later found partially pushed in by the desperate victims, Tbeir hysteria was so great that a man in a wheelchair, caught in the wild panie, was later found with his feet jammed between the half-open door and the gaping elevator shaft. Coroner Arthur J. Pearse thought some died of sheer fright, and one panicked man jumped to his death from a fourth-fioor window.

Some escaped almost immediately from the spreading gas and fire. Custodian Adams was the first person out of the building, his clothes aflame, Boggs, the unfortunate discoverer of tbe film fire, was blown by tbe second blast into a windou» well in the clinic's basement. He clambered out of it and ran to the East (05th Street Fire Station, shouting, "There's a terrible fire at the clinic, a big fire!"

Long before Boggs arrived, at 11:30 A.M, , the first alarm was turned in from a firebox. The Eighth

An assortment of volunteers joined the officiai rescue squad and their equipment on the rooftop, where they struggled to revive victims. Cleveland Public Library, Photograph Collection

Traffic near the clinic quiokiy became snaried. Police set up a cordon to keep the curious at a distance. Cleveland Rublic Library. Photograph Coilection

26 TIMELINE

A number of policemen and liremen conducted rescue efforts via the clinic's windows. The fire department's army- surplus gas masks proved inadequate, and oxygen-supplied helmets were needed to complete the removal of victims. Cieveiand Public Library. Photograph Coiiection

Triage and first aid were performed on the front lawn of the clinic before the victims were rushed to area hospitals. Cleveland Pubiic Library. Piiotograph Coitecticn

Fire Battalion, under Cfiief Graham, roared out of the firehouse. They could smell and see the dense, yeilow-hrown smoke before they got to the scene, and, by the time they arrived at 11:40 A.M., fires were raging in the film room, rear elevator, and rear stair- well, with six minor fires elsewhere in the building.

Fortunately for those trapped in the clinic, spontaneous rescue efforts had already begun. A. W. Johnson and Roy Miller were up on forty-foot ladders, painting a sign just west of the clinic, when the first blast occurred. Seconds later, Johnson saw dense clouds of "umher" smoke pouring out of the building. He and MiUer grabbed their ladders and ran with them to the west wall of the clinic. There, joined by a young man named Walter Jackson, they ran the ladders up to second-floor windows, where terrified people were screaming and even hanging onto the sills to avoid gas pouring out of the windows Jackson, Miller, and Johnson, joined hy others, climhed up and began to take frantic, often injured, victims down, one by one. Except for Jackson, a veritable Porthos on that fatal May day, as one impressed witness later testified: "I saw him walk with two people down the ladder the same as you would go downstairs." Jackson soon topped that feat, actually holding a ladder with his hands and shoulders so rescuers cotJd climh higher.

Many others hecame heroes that terrible day. Patrolman Ernest Staah was near the clinic when the fire started and rushed into the building. He pulled twenty-one bodies out before he collapsed. Like many of the day's heroes who survived, he paid

a continuing price: he was subject to fainting spells for months after the accident and suffered for years from aftereffects.

Some heroes came in groups. One such was composed of pupils from the Wilcox Commercial School on Euclid Avenue at East 100th Street. Ignor- ing the orders of firemen at the scene, they entered the huming clinic and hegan ptilling victims out.

Eight doctors and six nurses died, most of them succumbing as they tried desperately to save their patients. Among them was Dr. John Philhps, one of the clinic founders. Escaping from the clinic, he worked outside for hours, treating the victims spread out on the grass. That evening, he collapsed at his

My ' August 2002 27

A piece of clinic furniture became a makeshift stretcher. Cleveland State University, Cieveiand Press Oailection

Ciinic interns worked aiongside volunteers. Cleveland State University, Cieveiand Press Ooilection

apartment and expired, despite the frantic efforts of Dr. George Crile, another founder, to save him.

William Erownlow, clinic medical artist, died bravely. He was in his tbird-fioor studio and already succumbing to gas wben usher Susan Brantweiner ran in. As he attempted to smash a window, sbe crawled across the floor to him and said, "Goodbye." Brownlow muttered, "No, not goodbye," shattered the window, grabbed Brantweiner, and thrust her into the air outside. Firemen eventually rescued her, but Erownlow refused to go until two other victims had been removed from the room. He died soon after. Many survivors would never forget coura- geous nurses shouting, "Save the patients, save the patients!" as death closed in.

A second and more-powerful explosion occurred several minutes after the first firemen arrived on the scene. It was probably a blessing, as it blew out many windows and firemen could see victims who had been hidden by smoke. It also blew out the skylight, thus ventilating much of the toxic gas in the three-story interior court. Within minutes, firemen had snaked their new, eighty-five-foot motorized ladder to the roof. Descending through the ruined skylight, firefighters Howai-d McAllister and Peter Rogers were lowered into the smoke- and gas-filled interior court. Swinging from side to side, they finally got inside the fourth-floor railing and began puliing victims, packed four deep in some places, out of the stairwell and elevator areas. They sent fifteen victims to the roof, some dead, and some who were revived by Pulmotors. So many bodies were taken to

tbe county morgue tbat tbey had to be laid out on the floor for identification by stunned relatives and clinic staff.

It was all over by 1:15 P.M., although a third explosion came shortly after the second. All victims had been removed, and all fires were under control. It was not over, however, for many of the victims. The lingering or delayed effects of the gas were potently manifested in the fact that some victims quoted in early newspaper accounts showed up in later editions as fatalities. Some fought death for hours, some for days; attorney Hemy Lustig battled until June 13, almost a month alter the disaster. The last two victims of the clinic disaster died almost a year later from lingering efiects, ieaving the final toll at 129.

If careless in the procedures and conditions that produced the disaster, the clinic's personnel were magnificent in response and recovery. Crile himself

28 TIMELINE

When the available ambulances were overwhelmed, a fleet of taxicabs, commercial trucks, and private cars removed the injured and dead, Cieveiand Pubiio Library. Photograph Ooiiection

The telephone company set up a bank of phones at the morgue and provided an operator to answer calls from family members. These emergency lines were set up on a pole outside the clinio. Cieveiand Clinic Archives

Shortly after one o'clock, officials reported that everyone had been removed from the building. Some rescuers were served a late iunch, Cieveiand State University. Cieveiand Press Coiiection

was at his best throughout the disaster, a veritable battlefield general who tirelessly marshaled resources to heal the wounded and console the grieving. After hours tending the injured, Crile established a new clinic headquarters across the street in an old man- sion and announced; "We must carry on. The cîinic has its work to do and must go forward."

As the clinic's efforts to rebuild and recover went forward, so, too, did efforts to explain the unprece- dented accident. City, county, and state probes commenced, supplemented by investigations by the War Department, Western Reserve University, the Bureau of Standards, and tbe National Board of Fire Underwriters. The results of these various inquiries are best summarized by noting that they held no one liable for tbe tragedy, and they agreed

that tbe disaster never should have happened, given existing knowledge about nitrate-base film. Provoking much criticism. Coroner Pearse's inquest was held in private, owing, he insisted, to the reluc- tance of witnesses to testify in public. After lengthy sessions involving dozens of witnesses, Pearse concluded there was no need to call a grand jury to investigate or apportion blame for the mishap.

Probably tbe most thorough inquiry was the clinic's own, undertaken by some of the city's best lawyers. Interviewing virtually all clinic employees and disaster vritnesses, tbey narrowed tbe disaster's origin down to three possibilities: (1) "spontaneous" combustion of the fiim, owing to overheating of the storage room; (2) film combustion caused by a carelessly left cigarette or match (hence the persis-

July • August 2002 29

Among the federal officials who rushed to Cleveland to assist in the disaster investigation was iHarry Gilohrist (right), chief of the army's chemical warfare service and a wartime friend of Crile (left). He also advised clinic physicians on the treatment of fhe gas victims. Crile's son, then a student, joined the two men in examining the disaster scene. Cleveland Public Library. Photograph Collection

tent inquiries about the smoking habits of Buffery Boggs); or (3) film combustion caused by contact with the extension cord light dropped over the "big spike" near the film racks.

No one ever proved that Boggs, or anyone else, was smoking in the film room that day, altbougb charwoman Rose Rebar testified that she often saw people smoking in the clinic basement. And, while Fire Warden Joseph H. Andrews bad found a pack of cigarettes in tbe film room only five days before the fire, no tobacco evidence was found to support the "careless smoker" tbeory.

Tbat left the one-hundred-watt bulb at the end of the spike-draped extension cord as tbe probable cause of tbe mishap. It was found in tbe ruins of the film

Tji.- CLEVELAND PLAIN DEALER EXTRA

Ü L L I D BY GAS AND FIRE ^ IN BLAST-WRECKED CLINIC:

BODIES OVERFLOW MORGUE

storage room, encrusted witb film residue, and Enid Critcher tesfified that she had employed it for several months up to the day of the disaster. Custodian Walter Adams adamantly insisted it wasn't there: "As for that light bulb extension, if it was there after tbe fire, ghosts must have placed it tbere. We took special pains tbat the 100-watt bulbs were not within three feet of the x-ray films." On May 24, the Plain Dealer noted tbat one of the chief wit- nesses in the city probe of the clinic disaster had made "false statements" and that "tbey concerned the ligbts in the basement room." But no one was ever legaüy cbarged with negligence or culpability in the clinic tragedy.

The National Fire Protection Association was not so kind in its assessment. On June 12 it issued a report that blistered botb the city and clinic for sloppy practice in handling and rcguladng x-ray ñlms:

It is inconceivable that tbe conditions responsible for the Cleveland hospital disaster could have been permitted to exist even for a single day bad the management or tbe inspection authori- ties appreciated the hazard....There was a large quantity of nitrocellulose x-ray film in tbe basement. It was stored in

As the county morgue rapidly filled, newspapers published front-page lists of the dead, Cleveland Clinic Archives

30 TIMELINE

A city inspector searches the x-ray tile roon for ciues to the cause of the tragedy. Cleveland Public Library, Photograph Collection

An innocent-looking iighting fixture in the fiie rocm received close scrutiny during the investigations. Cleveland Stats University, Cieveiand Press Collection

obvious violation of proper precaufions for the keeping of this material of known dangerous property.

No expense or expertise was spared in trying to ardve at a scientific understanding of the clinic disaster. Elaborate tests were conducted to determine the toxieity of tbe probable gases involved. Mice exposed to burning gas-residue scrapings from tbe clinic walls — tbere were copious yellow-brown

stains throughout the building — convulsed and died uathin one to two minutes. The official probes and harmless recriminations dragged on for months.

The clinic, however, had already put it all behind. Tbe Cleveland establishment, led by philanthropist Samuel Mather, rallied behind the clinic, and Crile impressively rebuilt it from the ruins of May 15, 1929. The interior of tbe main building was radically restructured, to spare the sensibilities of tbose who migbt remember its original look. The insurance claims were paid off. And the clinic only waxed more glorious as a Cleveland, indeed global, in.stitution in the years afier. It did, however, switch to acetate- base film and enforce some safety regulations and recommendations concerning x-ray film storage.

Why did tbe clinic disaster happen? No person was ever held accountable, so it is now a moot point. But some notes on the clinic's ñre inspections during the 1920s raise intriguing questions about municipal inspection procedures and enforcement. On May 4, 1925, for example. Fire Warden Andrews inspected the füm storage room and ordered the clinic to keep its x-rays in metal containers and to provide a fireproof vault for same. This, obviously, was not done. Four months later, on September 15, Andrews made his last inspection and warned clinic officials not to allow smoking in tbe film area. There is no evidence that any of his recommenda- tions were ever implemented. "U-

July 'August 2002 31

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