Deadly Gases From X-Ray Films

Deadly Gases From X-Ray Films


Pages from the Past

Ladders reach to windows and roof of Cleveland Clinic, where 125 lost their lives.

Pacific & Atlantic Photos

There were about 250 persons in the Cleveland Clinic, a four-story, reinforced concrete frame, brick wall, 75 x 124-foot building in Cleveland, Ohio, at about 11 a.m. May 15, 1929, when a “cloud of yellowish smoke” was discovered in a basement storage room for X-ray film. Two hours later, 125 persons were already dead or would die from the fumes within a couple of days.

About 50 other persons were treated in hospitals for the effects of the gas.

A report published by the National Board of Fire Underwriters and the Ohio Inspection Bureau stated:

“Alarms were turned in from several places by telephone. First alarm officially recorded was at 11:30 a.m., the second at 11:34 and the third at 11:44 from Box 315 at Euclid Avenue and East 89th Street, two blocks west of the building. The companies located at Euclid Avenue and East 105th Street, under Battalion Chief (Michael) Graham, were first to respond. The odor of burning nitrocellulose was noticed several blocks east of the building, and the building was almost obscured by a dense cloud of yellowish brown vapor. A second alarm was sent in at once.

“The first alarm brought two pumpers, one ladder truck, one rescue squad and two battalion chiefs. Second alarm brought two more pumpers, one more ladder truck, another battalion chief, and the second assistant department chief. Battalion Chief Graham ordered ladders raised on the west side of the building and began a circuit of the premises. Battalion Chief Flynn joined him at this time. Reaching the southwest corner of the building they saw fire through windows in the rear stair shaft and ordered a hose stream on it. A great volume of flaming gas was coming out of the two basement windows nearest the east side. On the east side, the chief found the windows filled with people. No one had been seen at the west or rear windows.

Gas prevents entry

“At this time the order was given for a third alarm with specific instructions to send two more rescue squads. Chief Graham and a member of the rescue squad put on gas masks and tried to enter the building. They reached the front stair landing below the second floor but were forced out of the building by the concentration of the gases. An attempt was made to use an oxygen helmet, which failed because it was not properly adjusted on the man.

“A 50-foot ladder was raised to the roof, and two firemen were attempting to reach persons in a window when the explosion occurred tearing out both skylights and parts of the ceiling of the fourth story. No explosion had been heard since the arrival of the department, a matter of some eight to ten minutes. The blowing out of the skylights liberated a vast cloud of brown vapor, clearing the building of gas; people then could be seen at all windows, which was the first time anyone had realized that so many people were in the building. The rescue work began in earnest. Men with stretchers, both firemen and volunteers, removed people from the inside and every available ladder was used in removing people from the windows. Victims were also lifted through the small skylight over the front stairs to the roof where attempts were made to revive them. Immediately after the explosion, fire broke out in curtains and light combustible material in six different places throughout the building. Various hose lines were put into operation, principally in the basement and in the rear stairway and elevator shaft, where the gases of decomposition were burning in a typical blow torch flame.

“The rescue work continued. People were brought to the front lawn to be examined by Clinic physicians and rapidly dispatched to hospitals in every available vehicle. Approximately 250 people, doctors, nurses, employees and patients, had been in the building. By 1:15 p.m., everyone had been removed and the fire was out except for smoldering window frames and a little wood in the roof space near the rear stairs.

Piles of bodies found

“Rescuers found the dead and dying piled in the stair landings and in the hallways at the front elevator. By far the greatest number of victims were on the third floor. Life nets were used but very few people jumped from windows. Most of those taken out of the building on ladders leaned out of the windows or hung on sills outside until rescued.”

Fire Engineering reported, “The rapid decomposition of the (nitrocellulose base) film liberated vast quantities of poisonous, yellow fumes. The building had a modern ventilating system, and the immense volume of fumes that was generated was sucked up throughout the building by the fans that were installed to bring fresh air to the patients.”

The “deafening” explosion that occurred eight to ten minutes after the arrival of the first fire companies shook the building and caused a stampede of men and women to doors, windows and elevators.

Enter through skylight

Unable to enter the building through the doors because of the gas, “two firemen finally reached the roof and hacked their way through the skylight,” Fire Engineering said. “Inside, they found bodies packed deep in the space between the elevator and the stairway. Some of the victims were raised up to the roof through a trap door. Many were dead, but some showed signs of life. Inhalators were sent up to the roof and used.

“Chief Graham was lowered into the building and found the crushed bodies of 10 persons who had been trampled to death in the mad stampede for exits. When it became apparent that rescuers would have difficulty in gaining entrance, Chief Graham ordered inhalators into the building, and while Firemen with hose stood alongside preventing the advance of flames, applied respirators and worked on patients so that they could be taken outside partially revived.

“Once entrance was gained, firemen and others commenced bringing victims out so fast that doctors and first aid workers on the lawn could not cope with the situation.”

A fire fighter who peered into the building through the skylight was reported to have said later, “I hope never to have to look at anything so horrifying again. Lord help men, as far down the stairway as you could see were bodies, bodies, bodies. Twisted arms and legs, screaming men and women. Bodies and screams.”

This tragedy had an inauspicious start. The underwriters’ report written by F. E. Greene, an inspector for the Ohio Inspection Bureau, and H. E. Newell, an engineer for the National Board of Fire Underwriters, said that a steam fitter went to the clinic about 9 a.m. to repair a leak in a 65-psi, 4-inch steam line in the northeast, corner of the basement X-ray film room. After he removed magnesia insulation near the leak, “a jet of steam about 3 feet long issued from the pipe in the direction of the film rack against the north wall.”

The steam fitter went to the detached power house on the property to shut off the steam and then he went back to his shop while the line cooled.

Sees yellowish smoke

“Shortly after 11 a.m.,” the report continued, “he came back to the film room, where he discovered a cloud of yellowish smoke about 5 feet square in the northeast corner of the room near the ceiling. He immediately secured a 2 ½-gallon extinguisher from the machine room, which he emptied in the general direction of the smoke.

“The steam fitter was overcome by the fumes, fell to the floor, was revived by a draft of fresh air and started for the door of the room on his hands and knees. A slight explosion threw him through the door into the machine room. He ran to the maintenance man, who was working at a bench across the basement from the file room, and together they made their way through a window and areaway out of the building.

“Another explosion occurred when the men were at the window. The building superintendent, who was in the basement when the steam fitter called for an extinguisher, ran out to spread the alarm.”

Even X-ray department employees did not know the number of films in the storage room, according to the underwriters’ report, but “it is estimated that there were about 70,000 sheets, or 4200 pounds of film of all sizes, with some estimates of as much as 10,000 pounds.”

Insideous effect of gas

The lethal gas was insideous in that some of its victims felt no effect until it was too late. One man brought out of the clinic protested that he was all right.

“Don’t do a thing for me,” he said. “The gas didn’t bother me. Get the others who are dying.”

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Five minutes later he collapsed. Fire fighters put him into an ambulance. He was dead before he reached medical aid.

It was reported that a professional football player participated in rescue operations and then returned to his home, happy that he had not succumbed to the gas. He died 48 hours later as a result of his exposure to the gas.

Clinic founder dies

Dr. John Phillips, one of the four founders of the clinic, received a blood transfusion from one of the other founders, Dr. George W. Crile, but the gas still had its fatal effect.

A story of the tragic fire in the May 29, 1929, issue of Fire Engineering reported: “A traffic policeman who was stationed near the hospital rushed in and started to carry out a woman. He staggered, fell, regained his balance and then fell again. Fellow officers found his body 15 minutes later.”

Another policeman, the same article stated, removed “21 persons from the gas-filled clinic before he died. Bodies were rushed to hospitals in the city and when examined, were found to be lifeless.”

Dr. William E. Lower, another founder of the clinic, said in a formal statement that nitrogen dioxide from the decomposition of nitrocellulose X-ray films caused the deaths of the 125 men and women.

The underwriters’ report said of the deaths: “One person was killed in a fall to the ground. No one was burned to death or killed outright by the explosion. The larger number died from the effects of the gases, some living several hours or days after exposure.”

Composition of gases

This report, commenting on the products of decomposition of the X-ray film, said, “Approximately 30 percent of the gases were carbon monoxide, which contributed to the destruction of life as well as property. Of the oxides of nitrogen, it is probable that nitrogen peroxide was the only one present in any quantity …. Nitrogen peroxide probably constituted about 30 percent of the gases and would cause death because of its corrosive action on the human tissues.”

The underwriters concluded, “Lack of air in the room prevented free burning of the film, hence a great quantity of gas was passed out of the film room into the machine room and through the pipe tunnel (which ran around the perimeter of the building at the basement level), up the pipe ducts and through the entire building. The gases must have been heated past their ignition point, hence flashed on contact with air.

“As the fumes became mixed with air, they burned intensely in the rear stairway and elevator and in the southeast corner of the basement (which was under only about a third of the clinic building area). The explosion which destroyed the main skylight and broke a great many windows occurred about 15 minutes after the fire started and 8 to 10 minutes after the firemen arrived. This explosion may have been caused by flame lapping against the inner skylight, igniting gases confined in roof spaces or by ignition of gases in the pipe shafts on (the) west side, where evidence of fire is (sic) found.’

Three theories

How did the underwriters think the fire started? Their report offered, without any firm conclusion, three theories:

“Of the theories advanced as to the origin of the fire, three are logical. The first is that decomposition of the nitrocellulose film was caused by the rise in temperature brought about by the uncovered steam line and by the leaking high pressure steam. Steam at 65 pounds pressure has a temperature of approximately 312°F; decomposition in film starts at about 275°F. The film nearest the leak in the northeast corner of the room could be expected to decompose first and it was in this corner that the steam fitter found the cloud of smoke.

Damage to hallway at Cleveland Clinic is relatively light compared to death toll.

Pacific & Atlantic Photos

“The second theory, and perhaps the most widely accepted, is that the films were ignited from an incandescent lamp attached to a portable cord suspended in front of the shelving in such a way as to start decomposition from the heat of the lamp.

“Another theory is that a lighted match or a cigarette stub was dropped on or near the films by someone who had gone into the room shortly before the fire.”

The X-ray storage room was originally a coal vault and was about 19 x 24 feet. Its use as such was discontinued when the separate boiler house was built to supply steam for both the clinic and the adjacent hospital with which the clinic was associated.

Fire doors fail to close

The underwriters’ report noted that the single door of the brick-walled storage room had “an approved class C tin-clad fire door hung in an angle iron frame. The closing device was not in operative condition at the time of the fire…. There was a direct communication between this room and the 4 x 6foot pipe tunnel… from which the pipe ducts extended through partitions to the roof spaces.”

It is interesting to note that in a paragraph later in their report, the underwriters stated: “The fire door on the entrance to the film storage room in the basement failed to close automatically owing to the counterweight lever striking against a steam pipe.”

This was not the only fire door that failed to close. Continuing in the same paragraph, the report explained, “The fire door between the elevator hall and the machine room (in the basement) was prevented from closing by the weight becoming jammed between the wall and the upper hinge. The fire door between the stair and elevator hall was blocked open with a barrel.”

Other doors helpful

This paragraph in the report also noted the effectiveness of another fire door and some that were not actually fire doors.

“The fire door on the entrance to the tunnel to the boiler house closed properly, preventing the spread of fumes to the hospital and other buildings in the group,” the report observed. “The failure of three of the doors to close enabled the fumes to pass from the film room out into the machine room and thence into the stair and elevator shafts to the upper floors.

“All fire doors withstood the fire very well and can be put back in service when painted. The tin-clad wire glass panel doors on the stair and elevator shafts in the southwest corner of the building served their purpose, but will have to be replaced. Those that closed withstood the heat and permitted very little fire damage in the first, second and fourth stories. The stair door on the third story which was held open by a foot latch permitted the fire in the rear stair shaft to gain access to the third story.”

Fire doors save room

There was a small film drying room on the first floor that had an 8-inch-square hole in the floor to the pipe tunnel. This room was “badly burned” and although it had a doorway to a storage room for more current X-ray films than those in the basement, “a pair of swinging doors, 1-inch thick, and a pair of approved corrugated metal fire doors prevented fire from entering the film storage room.”

Although all the X-ray films in the basement storage room—even those in metal cabinets—were burned, “the evidence shows that the heat in this room was not very intense,” the underwriters stated. “Edges of paper records were charred, the wood pipe rack and bins slightly blackened and the wood cabinet only blistered.”

The report continued, “The rear stairway as far as the third story, the rear elevator shaft and much of the rear part of the third story showed evidence of intense heat, due to the burning gases. Above the third story, there was very little heat and practically no evidence of flame.

Where burning occurred

“Fire showed in three pipe shafts on the west side, in the southwest corner of the roof space and in curtains along the north wall of the fourth story.

“The southeast corner of the basement showed considerable evidence of heat. The concrete under the reinforcing bars in the joists was broken away at this point…. Wood window and door frames in the rear wall as high as the third story were badly burned from the outside.”

After examining the ventilating and heating systems, the underwriters concluded that the indications were “that these in no way contributed to the spread of the fire or heated gases. From the condition of the interior walls and partitions, it is evident that the gases found their way into the pipe tunnel previously described and ascended to all floors by means of the pipe chases.”

Lessons learned

This fire underscored what already was well known about the decomposition characteristics of nitrocellulosebase film—X-ray, movie or still camera. The underwriters concluded that even if the fire door to the X-ray storage room had closed properly, the results would have been “problematical” because of the part played by the pipe tunnel and vertical pipe shafts and “the fact that the film vault was not properly vented and not equipped with automatic sprinklers.”

The report pointed out that water will absorb “a considerable portion” of nitrous fumes.

“The water spray from automatic sprinklers is, as a result, very effective in reducing the possibility of danger from this undesirable feature (nitrous fumes),” the underwriters declared. “While only a small percentage of the other gases are absorbed by water, the water spray cools them below the ignition point and also saturates them with moisture. They therefore will not take fire spontaneously when they issue from vault or room and are more difficult to ignite subsequently, due to their water vapor content.”

Acetate-base film is now standard not only for X-ray films, but also photographic and movie films. Certainly the Cleveland Clinic fire provided impetus to the switch to acetate, or safety film.

Mistakes continue

Unprotected pipe chases played a large part in the movement of lethal gases. Ducts can have smoke dampers and even fire doors, and this is required by codes for certain installations. Pipe chases can be fire-stopped. Although building and fire codes require this, the fire-stopping is frequently breached and sometimes omitted even today.

If they are to do what they were installed to do, fire doors must be maintained in operating condition and frequent inspections must be made to make certain they are not blocked open either intentionally or accidentally.

Unfortunately, the human errors of blocking open fire doors, wiring open smoke dampers in ducts and breaching the fire-stopping in pipe chases are still being committed today, 48 years after the horror at the Cleveland Clinic.

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