The Wrong Bottle

In a laboratory of the University of South Dakota at Vermillion last week, young (28) Dr. Louis F. Michalak blacked the foreheads of two human guinea pigs with India ink to make the skin more heat-absorbent. The doctor tested their "pain threshold" with the heat from a 1,000-watt lamp. After taking their normal readings, Dr. Michalek reached for a pain-killing drug to inject. He meant to give them Demerol (safe dose: 100 milligrams). Then he would repeat the test on a third volunteer and himself, using methadon (safe dose: 10 milligrams). More pain readings were to follow, to show the effect of the drugs.

Dr. Michalek gave100-milligram injections to Jack Clifford, 30, a lab technician, and Mrs. Ardys Pearson, 26, a secretary. As he reached for the methadon bottle to give the much smaller injections to another secretary and himself, the physician drew back in shock. He had used that bottle the first time. He looked quickly at Mrs. Pearson; she was already in deep distress. Dr. Michalek called for antidotes. Then he picked up the phone and told the dean: "I think that maybe I might have made a mistake on the dosage, perhaps."

There was no perhaps about it. Dr. Michalek had given tenfold doses of methadon to both Clifford and Mrs. Pearson. He injected antidotes, and stimulants (oxygen, Benzedrine, adrenalin) were given later in Dakota Hospital. But within 24 hours of what started as a routine experiment, Dr. Michalek stood by Clifford's bedside as he died, then at Mrs. Pearson's and saw her die, too.

At the inquest, State's Attorney Martin

Weeks asked: "Were the bottles labeled?"

"Yes," said Michalek.

"Did you read them?"

"Yes."

"Then how do you account for this mistake?"

Looking earnestly at his inquisitor through heavy-rimmed glasses, Dr. Michalek said: "It's one of those things you can't account for. You check it, and then you just don't know how to account for it."

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