(gentle music) - [Narrator] In December of 1960, the New England Journal of Medicine shared a case study involving a rarely performed but potentially life saving medical procedure called peritoneal dialysis.

The author of the study was Dr. Lawrence Finberg, a professor of pediatric medicine at Johns Hopkins University in Baltimore, Maryland.

Peritoneal dialysis, a treatment used to remove toxins from the body through an exchange of fluids in the abdominal cavity had originally been performed in the 1920s, but 40 years later remained a medical outlier that only a handful of doctors were aware of and few knew how to perform.

Dr. Finberg was one of the few, just 37 years old, Finberg was a rising star in the field of pediatrics.

He had earned the reputation as a brilliant doctor with a big heart, who reportedly watched over his young patients with the sheltering possessiveness of a mother bear.

He was often spotted deep into the night walking the halls of Johns Hopkins Medical Center, softly singing to a sick child, cradled in his arms.

Utilizing the peritoneal treatment, Finberg had weeks earlier saved the life of a 16 week old girl who'd been rushed into a neighboring Baltimore hospital, vomiting and having seizures.

The infant had inadvertently been fed high levels of a common but potentially dangerous household ingredient, salt.

The child's case alarmed Dr. Finberg for multiple reasons.

The baby girl had come close to death and before he was called the emergency room, doctors had no idea what was wrong or how to treat her.

Although the dangers of salt poisoning have been known for some time, Finberg would write, "The amount of a toxic dose is not generally appreciated."

Finberg knew that less than two tablespoons of sodium ingested by a child less than 18 months old would trigger a systematic failure of the infant's critical organs.

If the excess salt was not removed before it reached the infant's brain, permanent damage or death was likely.

Finberg concluded his report with an ominous warning.

The violent and clandestine nature of sodium chloride's attack on the body, especially in infancy, is caused for serious concern, coupled with a lack of anecdotal data and research and inadvertent case of salt poisoning, particularly on a mass scale, possesses the capacity for catastrophic results.

(gentle music) Less than two years later, Finberg's worst fears would become tragically real in the maternity ward of Binghamton's General Hospital.

- [Narrator] Production support for this program was provided by Linda Beamer, Bill and Tracy Maines, Judy Siggins and Bill Isbell.

Kent and Heather Struck, the Community Foundation for South Central New York and by viewers like you, thank you.

(baby cooing) - [Narrator] Tuesday march 6th, 1962 was a busy day in the maternity unit at Binghamton General Hospital, and it sounded that way.

The distant delicate cries of hungry newborns added a sweet sprinkle of melody to the chorus of squeaky shoes and clinking carts that echoed throughout the ward.

Five additional births that morning had pushed and already understaffed nursing crew to their limits.

By lunchtime, there were 38 newborns in maternity on the building second floor.

Another 12 infants and toddlers were upstairs in pediatrics on the third floor, there were just four nurses assigned to the 7:30 to 3:30 shift.

No nursing supervisor was on duty that day.

(gentle music) The maternity building on Mitchell Avenue was still relatively new in 1962.

It had been built less than a decade earlier during the post-war baby boom to replace the hospital's original infant ward on Park Avenue, which had been cited on numerous occasions for code violations, things had gotten so bad at the old ward, the city's fire marshal declared at a fire hazard.

A young mother in 1947 had nearly been electrocuted by an exposed wire hanging near her bathroom sink.

The new maternity unit was a state of the art beauty, equipped with enough beds and bassinets to accommodate 60 newborns and their mothers.

The coral blue and green painted walls evoked the feeling of a calming spa, which along with the knowledge, their infants were just steps away in two adjacent temperature controlled nurseries, the new mothers found pleasantly reassuring.

(gentle music) That Tuesday, Frank Belo and his wife Irene were in room 214 with their daughter Lisa Marie, who was born just three days before.

Frank was a photographer for the Binghamton Sun Bulletin and stopped by the hospital on his lunch hour to see his girls.

During his visit, the family got word from their doctor that Irene and Lisa would be discharged the next day.

After the doctor left, a nurse arrived to begin paperwork and promised the couple they would be sent home with a small supply of cloth diapers and several bottles of baby formula to help carry them through the next hectic days.

Donating parents a few bottles of formula had become a practice at the hospital's maternity ward, during the Great Depression, the staff knew many of the families they saw lived in the heavily blue collar neighborhoods that surrounded the hospital.

Most likely, they earned their living working long hours in one of the many factories in town.

The jobs were tough and money was often tight.

A few bottles and diapers was a small but meaningful gesture the hospital staff felt strongly about.

It was also in keeping what the hospital's founding pledge with goodness of heart and charity toward all.

80 years earlier, the nearest hospital to Binghamton was in Scranton, a long and bumpy 60 mile carriage right away.

At the time, If you could afford it, you hired a doctor to treat you at home or paid for a long stay at a specialized sanitarium.

The less fortunate relied on physicians of charity or the local OMS house.

In 1887 with Binghamton's population surging, city council members recognized the need for a permanent municipally funded medical facility.

What became known as City Hospital first opened on Court Street before moving in 1897 to Park Avenue on the city's south side.

Over the next 50 years, the hospital grew quickly when the new doctor's Memorial building was dedicated to great fanfare, in April of 1940, Binghamton City Hospital was touted as one of the largest medical facilities in the state, covering nearly four acres along Mitchell and Park Avenue.

By 1953, there were 500 doctors, nurses, technicians, and support staff scattered across 13 buildings with little centralization or interconnectivity, except for a few sub-level corridors and exterior walkways, making the transportation of patients and equipment cumbersome and unsanitary.

The new maternity building on Mitchell Ave was the first step in a 4 million decade long reincarnation of City Hospital.

By 1962, virtually every building department and operation had been analyzed and ready for renovation.

Even the hospital's name was changed to General Hospital to more properly reflect the facilities modern and expansive approach toward medical care as necessary.

As it was the near constant structural chaos worried the hospital's chief of Medicine, Jason Moyer, who expressed concern it was adding additional stress to his already shorthanded and overburdened medical staff.

At just 41, Jason Moyer was one of the youngest hospital medical directors in the country.

At his appointment five years earlier, he was asked by a reporter if his youth was a disadvantage.

Moyer laughed, "I hope it's an asset, this job requires the energy and push a younger man can give it."

A lack of energy had never been an issue for Jason Moyer, growing up, he spent countless days biking the streets of Hillcrest and Port Dickinson, delivering baskets of bread and brownies for Hills Bakery, where his father was president and CEO.

In 1942, just months after the Japanese attack on Pearl Harbor, Moyer joined the Navy.

His enlistment was deferred until he graduated from medical school in Montreal, Canada.

After the war, Moyer returned to Binghamton and built a successful and respected medical practice.

Moyer endeared himself to his patients by insisting everyone, call him Jay, and plastered his office walls at 80 Oak Street with photos of baseball greats like Lou Gehrig and Joe DiMaggio, stuffing his war medals and diplomas in a nearby drawer.

In 1957, Moyer surprised almost everyone by accepting the hospital's offer to run its medical operations.

His friends questioned his reasoning in walking away from a successful private practice for a highly public and largely thankless job.

But Moyer knew despite the endless critical press, the doctors, nurses, and support staff at City Hospital were hardworking, talented people who had already endured years of disruption.

Many were good friends.

"I guess I wanted to be part of the solution."

Moyer would confess years later, "Sitting on the sidelines didn't seem like the helpful option."

Barely a year into the job, Moyer was nearly the casualty of a hospital controversy.

In April of 1959, the hospital made headlines with news that two radiologists had been suspended for falsifying treatment records.

The doctors had attempted to conceal a mistake in the x-ray department that resulted in the death of an elderly cancer patient.

71 year old Elizabeth Cowan died after being exposed to six times the prescribed amount of radiation in a hospital lab.

The error had been made by a technician in the x-ray department when they read the wrong treatment chart.

When the news of Mrs. Cowans death and the attempted coverup hit newspapers, the hospital's board and city council needed a fall guy.

The new young medical director was an easy target.

That's when the hospital's medical staff rallied to his defense and saved his job for the moment.

But the message from the board was clear, any further issues would be dealt with harshly.

The scandal, however, did take a toll.

Moyer was hospitalized for acute anxiety and was forced to take a brief leave of absence.

When he returned, Moyer worked to minimize the renovations impact on his medical staff, which he believed provoked the error in the radiation lab.

It was a daunting task.

Moyer knew how shorthanded the hospital was.

Nearly every state inspection of the medical operations over the last decade had advised hiring additional personnel.

The recommendations included securing a permanent supervising nurse in the maternity ward on Mitchell Avenue.

At 2:00 PM that Tuesday in March, there was no supervising nurse on duty and maternity repeated attempts to find a qualified nurse to fill the position had been unsuccessful That same afternoon at 32 New Street, not far from the hospital, Dan Fabrisio and his wife, Arlene were worried about their daughter, Marie born just two months before Marie had developed a small bump on the right side of her waist, which her doctor believed was an inguinal hernia.

The Fabrisios were warned, if not treated soon it could become strangulated or knotted.

Their doctor scheduled Marie for admission the next day in the pediatric unit in General Hospital's maternity building.

The doctor's order included instructions to place Marie on one of the maternity's self mixed formulas.

At 2:15, It was early afternoon feeding time in maternity, and the nurses on duty were busy changing diapers and delivering hungry infants to their mothers.

The majority of the mothers in the ward that afternoon had chosen to bottle feed their babies.

Breastfeeding was nearing an historic low in the United States in 1962.

- [Narrator] With pet evaporated milk in the formula.

She's certainly getting a happy sturdy start in life.

While there is no better milk for babies than pet evaporated milk.

- [Narrator] Societal pressure, relentless advertising, and a fraternity of largely male pediatricians had successfully convinced mothers that commercially produced formula was more convenient and equally nutritious as mother's milk.

In 1962, less than 30% of American mothers would nurse their babies during the critical early months of life.

Binghamton General Hospital mixed their own infant formula in a dedicated room in the basement of the maternity building.

Several different formula recipes were in use dependent upon orders from the family's pediatrician.

With 50 babies in maternity and pediatrics that week, and seven to nine bottles needed a day for each child, the task of mixing, filling, sterilizing and labeling hundreds of bottles was a time consuming but critical assignment.

It was a duty that was generally assigned to one of the hospital's licensed practical nurses.

Since the end of World War II, the United States had dealt with a severe shortage of nurses.

- [Narrator] Four weeks of basic training finished.

The army nurse was ready to serve wherever the army needed her most.

- [Narrator] More than 60,000 nurses served during the war.

Many in combat zones, some achieving the rank of officer.

More than 200 were killed in service when the war was over.

Returning nurses hoped to be welcomed home having proven their considerable value in saving American lives.

Contrary to their expectations, home front hospital administrators and many doctors continued to see nurses as non-professional subordinate help nurses confronted low pay, low status, and miserable working conditions, disillusioned, thousands of nurses fled the profession.

Ironically, the exodus happened when they were at their greatest need.

Post-war advances in surgical and diagnostic methods increasingly required trained, registered nurses in operating rooms, pathology labs, and inundated maternity wards.

(gentle music) Since its earliest days, Binghamton City Hospital had trained its own nurses in what evolved over the years into a well respected school of nursing.

Many US hospitals had created similar nursing schools.

It was a convenient way to train nurses while also utilizing them for staff support.

The intent was that they would stay on after finishing their training, but by the 1950s, many of Binghamton's nursing graduates were being lured away by larger hospitals in bigger cities.

In the mid 1950s, New York State urged local school districts to open courses for training practical nurses.

A practical nurse required only a year of training before being licensed to work in a hospital.

Practical nurses duties were limited.

Only a registered nurse could assist in surgery, place IVs or dispense pharmaceuticals, but practical nurses could help ease the burden on the regular nursing staff.

In 1956, a training center for practical nursing began at Columbus School on Holly Street near downtown.

The school's director was one of the region's most experienced and universally admired nurses, Clarice Nap.

Nap had graduated from Wilson Hospital's Nursing school in 1929 and had been teaching and training young nurses ever since and would continue for the remainder of her 94 years.

In the fall of 1960, 27 year old Lilly May Colvin was hoping to become one of Clarice Naps, nursing disciples.

(gentle music) Born Lillian Mayfield in 1933, Lilly's father Leslie was a widely admired member and later preacher in the Baptist Church, her mother, Barbara, was part of numerous local charity groups who helped coordinate food and clothing drives, blessed with an enviable singing voice, at 16, Lilly formed a coral group with her younger sisters and friends from beautiful Plains Baptist Church on Pine Street.

The Field sisters attracted a wide audience appearing on local radio and television programs.

Married and a mother by 20, Lilly started cleaning homes to pay for shorthand and typing classes at Ridley Lowell in 1957, she landed a position in City Hospital's, x-ray division typing lab reports.

Records indicate she was one of the fastest and most accurate typists in the department.

When she left on maternity leave in November of 1958, she was given an efficiency rating of excellent.

She was back in radiology the following August before leaving to have another baby that spring.

That's when Lilly decided she'd had enough of the typing pool.

Lilly loved the hospital setting and desperately wanted to become a nurse, but the practical nursing school had filled its quota for the semester.

As fate would have it, Lilly had met Clarice Nap years before during one of the Field Sisters' Church concerts.

When Clarice saw Lilly's name on the list of standby candidates, she added an extra spot and moved Lilly to the list of accepted students.

(gentle music) The first five months of training were spent in the classroom where the ladies were schooled in anatomy, biology, dressing wounds, and caring for infants.

After a month break, they were assigned to either Wilson or General Hospital for the remainder of their training.

Lilly was assigned to work in General Hospital's maternity ward.

Already the mother of three active boys herself, Lilly enjoyed helping reassure overwhelmed mothers that all would be okay.

Lilly could calm a nervous mom just by the way she gently tuck their blanket, a colleague later remembered, I remember her sweetly handing me my baby one morning.

A mother would later remark, she said, here is your precious bundle of innocence.

She was kind and lovely.

It was heartwarming.

In September of 1961, Lilly May Colvin and 21 others passed the State's Practical Nurses Exam.

Lilly, as she had hoped was hired and assigned to the Mitchell Avenue Maternity Ward.

(gentle music) On Tuesday, March 6th, Lilly was one of four nurses and an aide working the seven 30 to three 30 shift.

Lilly was assigned to work the formula room filling in as she had before for the room's regular nurse May Pier, who was scheduled off.

There were three different recipes of hospital made infant formula in use at Binghamton General in March of 1962.

The recipes consisted of various combinations of evaporated milk and sterilized water.

Two of the recipes, stocks one and two prescribed to 14 of the infants in maternity and pediatrics used household cane sugar as a sweetener.

Lilly spent most of her shift mixing formula filling bottles and sterilizing them in an autoclave.

At 2:30, Before finishing up for the day, Lilly checked the small metal can that held the formula room's sugar supply.

The can was half full.

She placed it on a rolling utility card and headed down the corridor toward the hospital's main kitchen.

(gentle music) Long before Lilly headed in that direction, General Hospital's Kitchen had been under a steady dose of warranted scrutiny.

In 1958, In an effort to prioritize projects for renovation, a consulting firm was hired to analyze the hospital's entire operation.

In what became known as the Rourke Report, the kitchen was one of several areas identified as being in desperate need of immediate attention.

The report painted a grim picture, calling the kitchen too old, too small, unsanitary and lacking sufficient lighting in a particularly repellent entry.

The ventilation system was singled out as so inadequate that the operating rooms were repeatedly subjected to cooking odors from the kitchen.

While the kitchen received odors from the morgue.

The report recommended the kitchen be rebuilt and relocated a reality that was years away.

Shortly after the Rourke findings were made public, a food management firm out of Boston offered to perform a complete analysis of the kitchen's operations, free of charge.

Crady Brothers Food Inc managed dozens of institutional kitchens throughout the northeast, including the hospital in New Jersey, where General Hospital's new administrator, Gerhard Krems had previously worked.

Krems okayed and championed Crady's offer through City Council approval.

Three weeks later, Crady Brothers was awarded the kitchen management contract.

Crady brought in a new kitchen manager, RJ Stevens, to oversee the kitchen's operations, new chefs, stoves, and a $15,000 ventilation system were purchased to help cure the ailing kitchen operations.

(gentle music) The nurses who worked the maternity wards formula room likely viewed the kitchen drama with detached fascination.

Maternity didn't use the main kitchen for supplies.

When the formula room needed milk, sugar and other items, they went to a separately staffed and stocked diet kitchen across the hall from the main kitchen.

The nurse's aid who worked the diet kitchen would check the quality and freshness of the items, taste testing them before dispensing it to the formula room nurse.

It was a safeguarding measure in place for decades it.

But in 1960, shortly after assuming management of the kitchen, Crady Brothers suggested consolidating the diet kitchen with the main kitchen in an effort to save money and minimize waste, Gerhard Crems approved the move.

Jessie Lindo, the nurse's aid who worked the diet kitchen no longer had her own inventory of items.

Linde had to collect items from large containers that were spread throughout the kitchen, containers that dozens of others had access to, but Linde remained an important safeguard by continuing to check and taste test items before passing them on to maternity.

On December 2nd, 1961, Binghamton Police arrived at 19 Hancock Street.

The county coroner was with them.

The body of a woman had been found in her home by her sisters.

The woman was 34 year old Jessie Lindo.

She had died from an apparent overdose of sleeping pills.

Linda Dow's replacement directed formula room nurses to get any supplies needed themselves from the main kitchen.

In January of 1962, a nurse from the State Board of Health conducted a thorough examination of the entire formula room procedure, including the practice of obtaining sugar from the drums in the hospital's kitchen.

No changes were suggested.

That was the practice and how Lilly Colvin had been trained when she entered the hospital's kitchen the afternoon of March 6th, 1962.

Near the center of the room, sitting side by side were two identical 20 gallon galvanized containers.

They were similar to other containers in the kitchen that were used for food scraps and garbage.

Both containers sat on a separate rolling base.

The cans had handwritten labels on the lids and on their sides, the lid of the can on the left was marked sugar.

The label on the lid of the can on the right was slightly torn, but an SL and T could still be made out.

Lilly would later clearly remember reaching into the drum on the left and filling the formula room's, container with two scoops from the cans, contents that she assumed was sugar.

It wasn't.

Whether the lids of the cans had been inadvertently switched or lids was mistaken, which can she had chosen was never definitively determined.

The only certainty was the container that Lilly would return to the formula room that afternoon was now partially filled with salt.

(gentle music) On her way home Lilly stopped at the children's room of the public library to check out a book for her kids.

The Snowy Day was the first children's book to feature a child of color as its main character.

Lilly would later recall reading the story of Peter's playful adventures in a snow covered city to her young boys.

It would be one of the last moments of peace Lilly would remember for a long time.

The halls of maternity were calm as well.

That Tuesday night with visiting hours over, many of the moms stole a moment's rest while the night nurses tended to their babies.

The tired mothers flipped through magazines and chatted breezily with their roommates, grateful for the blanket of security the hospital had wrapped them in.

During the frenzied first hours of motherhood, a conscious realization of the moment had washed over some along with waves of fear and self-doubt.

The nurses dried tears and helped harvest hidden courage.

They listened with patient affection to their hopes for the future.

Misty evanescent dreams brought to life on the pages of the magazines the Moms held in their laps.

Wistful visions of the future made more complete by the tiny bundles that lay sleeping steps away in the hospital's nursery.

(somber music) On Wednesday morning, May Pier the regular formula room practical nurse began mixing formula using the contents of the container Lilly had filled the afternoon before.

Pier also mixed several bottles of formula to send home with Frank and Irene Belo for their daughter, Lisa Marie.

At 6:00 PM Wednesday evening, 14 infants including two month old Marie Fabrisio, who was scheduled for hernia surgery the next day began drinking the salt-laden formula.

By Thursday morning, March 8th, signs of trouble were already apparent.

Babies who had perfectly good appetites the day before struggled to drink.

A frustrated nurse was overheard saying, I don't know what's wrong with you mothers today, none of your babies will eat.

Another mother described how her child would turn her head away from the bottle, after a couple sips, I would turn her head back and just push it in her mouth, but she just didn't want it.

Helen Walker, struggling to feed her daughter Deborah shook a few drops of milk onto her wrist and tasted it, "This milk tastes salty," she commented to Lois, the attending head nurse in maternity.

"If you have a question about the formula your baby, is receiving," later admitted telling Mrs. Walker, "take it up with your doctor."

Other mothers later admitted tasting the salty formula, but were afraid to speak up.

(gentle music) Thursday afternoon, Frank and Irene Belo rushed their daughter, Lisa Marie, back to the hospital.

Lisa had also struggled drinking the formula and had begun throwing up, but back in maternity, Lisa was given more formula mixed with salt.

Throughout the day and into Thursday evening, the infants continued to show signs of distress.

Babies who were breastfed or on the recipe that did not call for sugar were fine.

No one made the connection.

No one checked the formula.

Sodium poisoning harbors a cruel nature.

The more the babies drank and vomited, the thirstier they got, with every sip, the chemical balance of their fragile bodies slid into disarray.

Some of the babies turned blue and ran fevers.

The symptoms tricked the doctors into believing a virus had invaded the ward.

Blood tests were ordered on the babies and their mothers.

(gentle music) By 1:00 AM Friday, six day old, Barry McPeak began having severe convulsions.

His eyes flickered violently.

His breathing became shallow.

At 4:40 in the morning, Friday, March 9th, Barry died.

Jason Moyer was called to maternity and told of the infant's death.

He gathered his medical staff.

They looked for possible contagions in the ward's cleaning supplies.

They checked how the pacifiers were cleaned.

They ordered blood tests on the babies to check calcium levels, they came back normal.

They performed a spinal tap on a young girl who had turned blue.

They found blood in the sample and ordered an intravenous calcium supplement, but there was no improvement.

All day Friday, May Pier continued mixing bottles using the container filled with salt and sending them to maternity.

At 7:30, friday night, four week old Glen Jones, who had been in pediatrics for over a week died.

Four hours later at 11:35, Helen Walker's three day old daughter Deborah Ann slipped briefly into a coma and died.

At 12:30 AM Saturday, Frank and Irene Belo were in a private maternity room, anxiously watching three different doctors trying desperately to save their daughter, Lisa Marie.

"She was drooling, and I just kept wiping it away for her," Frank later remembered, "I must have gone through three boxes of tissues.

She was wheezing and her hands were moving more than usual.

I thought she was getting better.

Her cheeks had a nice pink color.

Then around 12:50, she stopped wheezing and put her hands down, and it was just like that, she was gone."

Frank remembered watching the nurse slowly and delicately bundle Lisa in a blanket, gently cares her tiny head and hand her to his wife.

The nurse then walked into the hallway and collapsed in tears into the arms of another nurse.

On the third floor in pediatrics, another team of doctors hovered over eight month old Catherine Fleming.

Catherine had been in the ward since before Christmas battling cystic fibrosis.

She'd been getting better.

She was old enough to be fed baby cereal, which she took well.

She was also one of the first to receive the salt formula.

By Thursday night, Catherine had turned pale and was short of breath.

She was placed in a crew pet to help her breathe Around 3:00 AM Saturday morning, her temperature hit 104 degrees.

At 6:30 that morning, Catherine died.

Five babies had died in 27 hours.

Nine more were sick.

By Saturday morning, Jason Moyer desperate for answers, had called every doctor he knew at both Wilson Memorial and Lord's Hospital for help.

More than a dozen doctors were searching for answers to the crisis.

None of them thought to check the formula.

Moyer spent all Saturday in maternity, combing over infant charts and trying to rally a badly shaken nursing staff.

Rumors had begun to spread throughout the hospital.

Hushed whispers of a deadly out of control contagion rattled already frayed nerves.

At 11:30 Saturday night, a nurse found Jason Moyer alone in a small conference room at the end of the hall in maternity, his head buried in his hands.

She asked him if she could get him anything.

He looked at me through moist eyes and said, how do I end this nightmare?

(somber music) Sunday morning, Moyer left the hospital for the first time in two days to attend the early service at Trinity Memorial Church on Main Street.

At that same moment, May Pier was running late for her shift in the formula room with no time to make coffee, she poured instant crystals into a napkin and threw it in her purse.

In the formula room, she mixed her coffee and though knowing it was against the rules dipped into the formula room sugar container to sweeten her drink, with one sip, a sudden realization thundered through her.

Pier ran looking for Camilla Gail Waller, maternity's head nurse, unable to find her, she left a note for Gail Waller to call her immediately.

Then Pier made a decision she would later regret.

Taking the canister to the hospital's kitchen, she had it emptied and refilled with sugar, eliminating the tragedy's key piece of evidence.

At 9:45 AM Jason Moyer deep in prayer across town, was grabbed by an usher and summoned to the phone.

He rushed back to the hospital and gathered his medical staff.

They now knew what they were facing, mass sodium poisoning.

(gentle music) At 11:00 AM huddled together in the conference room.

Moyer and the other doctors soon realized that identifying the baby's predator wasn't as comforting as they had hoped.

None of them had ever dealt with a case of salt poisoning.

They had never even heard of a case, but in the room was the hospital's medical librarian, Marie Kwin, who remembered reading an article in the New England Journal of Medicine several years before.

20 minutes later, Dr lawrence Finberg heard his name page to a phone at Johns Hopkins Medical Center.

Finberg listened in disbelief as Moyer laid out the situation at the hospital.

He then told Moyer, time was critical.

If the salt wasn't diluted and removed within eight hours, permanent brain damage and more deaths were likely.

Finberg explained that peritoneal dialysis was the best chance to save the lives of the nine surviving infants fed the formula, five of whom were already in critical condition.

The others were in serious trouble.

No doctor at general had ever attempted the dialysis procedure, which required a catheter to be inserted into the peritoneal cavity in the abdomen to inject a dialysis, a type of cleansing fluid.

The dialysis would absorb the salt using the peritoneal cavity as a filter to remove the sodium from the fluid.

After a few hours, the salt fluid would be safely removed from the infant.

In 1962, the dialysis procedure on an adult was considered exceptional, on a newborn infant, nearly unheard of.

Finberg's 1960 Baltimore case was the only known success.

Finberg promised to leave for Binghamton at once, but knew he'd never get there in time to save the infants in the hospital's ICU, but he knew somebody who could.

(gentle music) John Kylie was a dialysis expert who worked at the medical college in Albany.

When Kylie heard from Finberg, he called in a favor with a friend at State Police headquarters who organized a convoy of troopers to rush Kylie to Binghamton.

Dr. Kylie was already on the road.

By the time Steven Schmick Broom County's district attorney arrived at the hospital along with detectives from the Binghamton Police Department, they had been notified by the hospital's acting administrator Carl Watney.

Watney had assumed the hospital's lead role just weeks before after Gerhard Crems had suffered a heart attack at his desk.

Attempting to get out in front of a police investigation, public scrutiny, and possible charges of negligence, Watney and members of the hospital's board narrowed their focus on the first target they could think of., the person who last filled the formula room's sugar container.

Lilly Colvin had been working in maternity all week.

She had grieved and helped comfort the shaken parents in the ward.

At five o'clock Sunday afternoon, Carl Watney summoned Lilly for questioning, at the same moment, the local press alerted by the police presence descended on the hospital.

After a brief internal investigation, Watney made the decision and announced to the media that he had suspended, Lilly May Colvin indefinitely without pay, there would be a full investigation.

Criminal charges were possible.

Press photographers captured the moment and overwhelmed and shaken, Lily Colvin was escorted from the hospital.

I have three small children of my own, Lilly told the surrounding reporters, I understand the heartache suffered by the parents who lost their babies.

I have done absolutely nothing wrong.

Lilly left the hospital trembling and in tears.

Carl Watney and members of the hospital's board were fielding questions from the media, at the same moment, John Kylie arrived from Albany.

Kylie had sent instructions ahead of time on what he would need to start the dialysis.

He had never attempted the procedure on an infant.

Any apprehension on his part was never apparent.

Kylie possessed an assured coolness that eased the battered nerves of the nurses assisting him, but the crisis was far from over.

(gentle music) Feeding charts showed three of the infants had ingested levels of sodium that would endanger an adult.

Blood tests revealed the salt had affected each endangered infant in different ways.

Calcium and potassium levels varied by case.

The dialysis solution to be injected into the infant's stomach would need to address each infant's mineral and electrolyte needs individually.

That was Lawrence Finberg specialty, but Finberg's flight had been delayed by strong thunderstorms.

Kylie would need to make a series of calculated guesses to start the process.

Jason Moyer operating on less than six hours of sleep in three days, approach the parents and explained why their infants were sick and what needed to be done to save their babies.

Already overwhelmed, the parents gave their consent.

Dan Fabrisio's daughter Marie was one of several infants who had received a lesser amount of salt formula and had been discharged before the discovery.

Those infants would need to return to maternity for evaluation and treatment.

Dan Fabrisio refused.

He'd lost faith in the hospital's ability to treat his baby girl.

They didn't seem to have enough staff to handle the matter, Fabrisio told a reporter.

Dan and his wife took Marie to Lord's Hospital to recover.

(typewriter clacking) In the dark overnight hours of Sunday, March 11th, wire services flashed breaking bulletins about the Binghamton tragedy to newsrooms across the country.

Monday morning newspapers from coast to coast boasted headlines of the salt poisoning deaths at Binghamton General Hospital.

Most papers included a picture of the suspended nurse under possible criminal investigation.

News of the infant deaths prompted a national spasm of shock, heartbreak, and fear.

Hospitals across the country were flooded with calls seeking reassurance that a similar mishap could not happen at their hospital.

Shaken parents began testing the cans of formula they were feeding their babies.

The Food and Drug Administration released a press statement confirming their commitment to oversight of the infant formula industry.

News of the tragedy touched the highest levels of government.

President Kennedy was briefed on the situation at General Hospital and reportedly considered a visit to console family members, but with his wife Jackie out of the country for a highly publicized trip to India, the idea was shelved.

Calls into General Hospital Monday morning, jammed the switchboard and overwhelmed operators, nervous family members of patients, demanded assurance the hospital's food was safe.

When people couldn't get through by phone, they started showing up in the hospital's main lobby, by 11:00 AM Binghamton Police decided to dispatch a uniformed officer to monitor the hospital's entrance.

(gentle music) At 11:22 that morning, four day old Michelle Bower died.

After fighting all night to save her, John Kylie was visibly angered by the child's death.

He hadn't slept since arriving the day before.

He needed relief and he needed Lawrence Finberg's experience with electrolytes to keep more babies from dying.

Finberg had again been delayed by weather this time at New York's Idlewild Airport.

By Monday afternoon, network television crews arrived at the hospital, including a young Dan Rather on his first assignment for CBS News.

An NBC news reporter was questioning Jason Moyer just as a threatening phone call came into the hospital's front desk.

- In Binghamton, New York Anonymous telephone callers phoned the General Hospital twice, warning that everyone there would be dead by eight o'clock tonight, and a caller phoned the home of Dr. Jason Moyer, the medical director, warning that he would be bombed and poisoned.

Binghamton police attributed the cause to crackpots that were on the alert for trouble stemming from the deaths of six newborn infants who died at the hospital apparently as the result of an overdose of table salt accidentally substituted for sugar, in their formulas, Dr. Lawrence Finberg, a John's Hopkins specialist who has done research in salt poisoning, flew to Binghamton to aid the hospital staff.

- [Narrator] Dr finberg finally arrived late Monday to relieve John Kylie.

By the time he was able to check into a hotel, Dr. Kylie had worked 36 hours straight, grabbing just an hour's sleep on an empty lab table.

The hospital's switchboard and Jason Moyer weren't the only ones to receive alarming phone calls.

The newspapers had published Lilly Colvin's picture, name and address.

The first call to her home came in shortly after the morning papers hit news stands, it was ugly, threatening, and blatantly racist.

Her sister Dorothea would later confess it unnerved Lilly like she'd never seen before.

After several more came in, Lilly took the phone off the hook.

By Friday, March 16th, all but two of the babies were off the critical list.

Marie Fabrisio recovering at Lord's Hospital was also out of danger.

(gentle music) But the community was still huddled under an umbrella of sadness.

Funerals for the babies who died were held under the relentless glare of the national media.

Frank Belo who made a living capturing images for newspapers, found himself on the other side of the camera.

Following his daughter's tiny casket from her service, he later admitted "I never took another photograph without considering the weight on the shoulders of the person at the end of my lens."

Multiple investigations of the infant's deaths and the formula making process were underway.

Binghamton police had confiscated the kitchen, salt and sugar drums and other material from the formula room, including the canister Lilly had filled and May Pier had used to make the formula.

Lilly was questioned by the Binghamton police, the hospital's administrator, the county coroner, and state investigators.

Her answers were always the same.

She was certain she had filled the formula room's canister from the kitchen drum on the left with a lid marked sugar.

While hospital and city officials focused much of their attention on Lilly's actions and the practices in the formula room, a journalist who had come to town to cover the story began digging a bit deeper.

Warren R Young was a science reporter for Life Magazine.

Young attended every hospital news conference and spoke to dozens of doctors, nurses, board members, even the porters who swept behind the salt and sugar drums in the hospital's kitchen.

Young would pen a 5,000 word essay on the tragedy that hit News stands on April 24th, just days before the coroner's inquest into the matter was to begin.

Young clearly laid responsibility for the incident on the shoulders of the hospital's, administrators, and local and state inspectors for not recognizing the breakdown of procedures in the formula room and for not correcting the blatant technical violation of placing the salt and sugar cans together in the hospital's kitchen.

"Drops of guilt fell like mist on everyone," Young would write.

Lieutenant John Gillin was a detective on the Binghamton Police Force, in 1962, Gillin was placed in charge of the criminal investigation of the infant deaths.

Gillin had grown up in Binghamton and had worked his way up the ranks from a patrolman.

He was admired as much for his meticulous investigative approach as he was for his avuncular nature.

Gillan spent three weeks tracing the path of the salt and sugar that ended up in the hospital's kitchen from the trucks that delivered it to the factory that produced and bagged it.

He interrogated everyone who had any point had come in contact with the kitchen drums or the formula room sugar container.

He had every remaining bottle of formula that May Pier had mixed before the salt discovery, shipped to the state police lab to be analyzed for the presence of other possible poisoning agents.

Gillon then went looking for any past or present hospital employee who may have held a grudge against the hospital or Lilly May Colvin.

Lieutenant Gillin completed his investigation but had not shared his findings with anyone before the coroner's inquest began on April 26th.

Criminal charges against Lilly Colvin or another hospital employee remained a possibility.

Lilly remained suspended without pay, nearly two months after the incident.

Broom County Coroner Vincent Maddy and District Attorney Steven Schmick would call 13 witnesses, including Jason Moyer, may Pier and Lilly Colvin.

Lilly was on the stand for over an hour and was asked multiple times to recreate her actions in the hospital's kitchen.

Several family members of infants who died were present in the courtroom, including Frank Belo and Gerald Fleming, who each had lost daughters.

Lilly Colvin's mother Barbara was also seated in the gallery.

Emotions in the courtroom were still raw.

When Jason Moyer was asked to read for the record, the baby's names and times of death, the courtroom silence was only broken by muffled strains of grief.

At four in the afternoon, after nearly five hours of witness questioning, Lieutenant John Gillin was called to testify.

He walked to the stand with his report findings in his hand, in characteristically thorough fashion, Gillin went through every aspect of his investigation.

At the end of his testimony, the district attorney asked Gillin one last question.

Lieutenant Gillin, were there any observations or conclusions that you made at the completion of the investigation as it appears in your hand?

Gillon paused scanning the courtroom until he found Lilly Colvin sitting next to her mother.

Our investigation, he said clearly and with precise directness was conducted for the sole purpose of determining whether a crime had been committed.

As a result of the investigation, I would say definitely there was no crime committed here at all.

Whatever happened was an accident.

Lilly's head dropped onto the shoulders of her mother, Jason Moyer sitting behind Lilly briefly placed his hand on Lilly's shoulder and walked from the courtroom.

Gerald Fleming, whose eight month old daughter Catherine, was the oldest infant to die, sat alone in the courtroom for an extended period of time.

He seemed to be staring at the drums of sugar and salt sitting nearby, A reporter would later write.

When asked by the reporter if he had any comments, Fleming quietly said, "I hope this starts to help everyone heal, and I hope something good comes out of this even though it will come too late for us."

(gentle music) On May 16th, the hospital board released the findings of their internal investigation determining that Lilly had made a mistake.

They never addressed the idea that the lids on the cans may have been transposed, but they did admit to many internal procedure shortfalls and decided to reprimand Lois Koons, the maternity nurse who failed to alert her supervisors about Helen Walker's salty formula complaint.

They made no mention of reinstating Lilly Colvin.

Ultimately, on June 20th, Gerhard Crems back from medical leave announced that Lilly would be able to return to work after the birth of her child in September, she would be given back pay.

However, Colvin would not be assigned to work in maternity.

She will be reassigned, Krems reported, to duties outside the infant formula preparation room for the time being.

Ironically, just below the newspaper article that announced Lilly's reinstatement was another story on the hospital's decision to investigate the operation of the kitchen and how it was managed by Crady Brothers food.

In this circumstance, the story states, the board finds that Crady Brothers was responsible for the position and labeling of the sugar and salt cans and for the issuance of the supplies therefrom.

It came with no surprise when it was later announced the hospital was ending its relationship with Crady Brothers Food Incorporated.

But the Crady Brothers troubles were far from over, two weeks after his death, the parents of Barry McPeak, the first infant to die, filed a wrongful death lawsuit against the hospital.

The parents of the other babies who died filed shortly after Crady was added as a co-defendant.

Each family sought different amounts of money with the largest claim filed at $400,000.

None of the lawsuits ever saw the inside of a courtroom.

"We didn't have a choice," Helen Walker later told a reporter, "We were taken into the judge's chambers and he told us if we didn't have the money to pursue the suit, then don't."

Frank Belo would angrily remark, we were sold down the river.

A hospital lawyer told us our baby had no monetary value.

Try telling that to the mother who carried her for nine months and then watched her die.

In 1964, the lawsuits were closed.

Each case was settled for $7,000.

After legal fees, the families each received around $4,200.

(gentle music) After the deaths at General Hospital, the New York State Department of Health, which had inspected the formula room procedure numerous times before the tragedy decided to add two new lines to the state's code that regulated the making of formula in hospitals.

Only those materials actually used in the preparation of formula shall be kept in the formula room.

All materials used in the preparation of formula shall be delivered to the formula room in their original containers.

Other states followed New York's lead in adopting stricter guidelines around the production of infant formula.

The Binghamton tragedy also ignited renewed study of the tremendous health benefits of breast milk.

By the early 1970s, a nationwide campaign to encourage mothers to nurse their newborns had gained widespread traction.

By the turn to the 21st century, over 75% of newborns in America were breastfed during the first months of life.

(gentle music) Several years after the tragic events at General Hospital, Lilly Colvin received a letter from one of the mothers who lost her daughter in the salt babies tragedy.

I know my baby's death was not your fault.

You and I and the other mothers will be forever bound by the memories and pain from that horrible event.

I pray our loss and our grief will help make us stronger, more caring women.

And I pray every day, we both find the peace we seek.

I know without a moment of doubt that it is what my baby girl would wish for all of us.

(gentle music) - [Narrator] Funding for this program was provided in part by the New York State Education Department.