The Murders of Shep Nuland and Dutch Van Milhoan
We start the book (Many People Many Passports, in progress) with two attempted murders, and will try to figure out how the stories of these most evil of human acts both contained good. We would not have wished for them to happen, but they were rather significantly large enablers of very good things, essential to my career. But why would master control have planned bad things in order to obtain good? No way would this be possible. Could our master control (DNA) have any other purpose than perpetuation of DNA in its playbook? Part of me that is Buddhist would vote that this was planned a thousand years ago. You ask why? If these things were random acts, it would be difficult to explain the wonderful coincidences that came together from Interplast and that continue to miraculously help. I would be dead 29 times over.
These murders (of Shep Nuland and Dutch Van Milhoan) are presented to you, my dear reader, as twin stories about death. But they are not grisly; they are the opposite: they show how there is some good in everything bad. In fact, now as I recall them, they bring me immense pleasure and I am smiling even before our start! I loved working in medicine for 54 years, and now enjoy writing about medicine – fantastic! Let us recall that our uncle and father, Hippocrates, provided us this wisdom in the form of a mandate: attain a skill and science for yourself, and then apply it for the benefit of the other person.
I. The Murder of Dutch Van Milhoan: a near-death experience
Larking Valley Rd., Aptos, CA, is an area that is bordering on wilderness. Dutch Van Milhoan lived here, head of his family. He rode a motorcycle and at times he raced it. He was obviously interested in living life to its fullest.
DRL was resident in his fourth year of surgery training at Stanford, on the San Mateo County Hospital rotation part of Stanford plastic surgery. The attending on call was Dr. Richard (Dick) Gonzales, who was a partner in Buncke and Gonzales Plastic Surgery, a great practice in San Mateo. He was heir to the Mexicali Brewing Company, and his wife was socially high and stately both in Mexico and San Mateo. Dick was handsome and wore nice suits. DRL was from the midwest: a hard, hard, hard workers who had been at Yale for three years in surgery residency and then to Stanford. Back in Milwaukee, Laub the medical student had been an aide-de-camp to the top plastic surgeons of the country when they administered the certification exam to the candidates in plastic surgery. And before that he had studies intensely under Dr. William Hamilton Frackleton. Later he was to start his research career in microsurgery and also laser removal of tattoos from the dermis of the human skin. He had invented and popularized the in-service examination to rate the cognitive knowledge and judgement ability of all plastic surgery residents across the country. He worked on spinal cord regeneration in the CFS (cerebrospinal fluid). This later research was the most significant of them all, because it was stem cells. In the midst of this, I was attracted to the immediate gratification and the psychic income associated with cleft lip repair, and transfer of the huge amount of skill and knowledge in the United States to those who didn’t have such in the more developing countries.
A Man, Bigger than Life
Dutch Van Milhoan took a shotgun blast at point-blank range, the round lead pellets of the .410 entering the base of his left hand at exactly the spot you might grab a shotgun from the rack over the front door of your home, as you are about to protect your family from harm, an act of self-defense, an act both defensive and natural, but also showing a bit of your aggressive tendency to protect the family. He had detected a potential enemy, or robber, or bad guy.. an enemy out there. You stand tall to reach the gun, stretch both arms, left-hand cupped over the barrel of the gun for stability, and the right hand on the stock; thumb over the trigger area, and…
The wound involved a loss of skin, muscle, and bone, as well as contamination by gunpowder and round lead pellets. The X-ray showed the drama of the situation: a through-and-through hole in the hand, the tissue splattered. But amazingly, the nerves and tendons were uninjured, in part because these structures are more resilient and tough and tend to move away from small-size impacts.
Fortunately, I had one-on-one actual hand surgery training in medical school rotation with William Frackleton and had come west from Yale with the up-and-coming premier hand surgeon, Dr. Robert Chase, and was able to obtain his consultation (not in-person, but by recalling his principles and training in my mind). I also obtained consultation in-person from Dr. Gonzales. The brilliant Gonzales advised me to use the Baylor hand immobilizer. An old technique, but new to our practice.
Each digit of the hand was to be held outstretched, and immobilized in order to heal the multiple fractures of the fingers and metacarpals. Rubber bands attached to the fingers with tape and pulled the digits out towards a big hoop.
The hoop was formed from thick and malleable copper wire, held in place with plaster of Paris in the forearm cast. The device stretched out in the shape of jai-alai cuesta.We frequently, each week, reviewed the ongoing X-rays to check the progress of the healing of the multiple fractures, adjusting the device into new positions. We were able to move the elastic bands around. We were amazed and pleased with this device and how handy it actually was.
When all change of infection had cleared and the healing had begun, we could safely transfer the tissue we had prepared in advance, on the first day after the injury which was a “flap of soft tissue skin and fat” from the abdominal area. It was a beautiful flap, taken from just where you would lay the palm of your left-hand onto the upper abdomen in a natural position, and was interestingly the same exact position in which he grasped the barrel of the “.410” on that fateful evening. Both skin and nice fat were included in the transfer of tissue from abdomen to hand, which we accomplished over a series of several operations, or surgical “stages.” True reconstruction and rehabilitation! We weaned the flap away from its nourishing blood supply on the abdomen by sequentially decreasing circulation by tourniquets, and then by operations to gradually close out the abdominal blood supply and force the tissue to gain new blood supply on both sides of the base of his hand. His hand was attached to abdomen for 3 1/2 weeks.
The patient’s body image resided in the function of his left thumb and fingers. I want to shift the Harley clutch, working with my left hand. This desire verbalized by Dutch became our overriding goal. In medicine and especially in surgery, one does not approach the physician as one would approach a clerk in a store, asking to purchase a specific item, providing the money, and taking the item home. Rather, the patient verbalizes an end goal, desire, or product. The surgeon offers or states his or her ability to deliver whatever he or she is able to deliver towards the patient’s stated goal, and in the next step, they both enter into a consensus as to what can be achieved and what will be acceptable by both working as a team.  It is not a buy-and-sell transaction nor a confrontational transaction, nor even a business deal. Both patient and surgeon form a unit, a team, and both devote whatever they have to offer to achieve the agreed-upon goal. Thus, they work together through the various stages of surgery, overcoming complications and obstacles, adapting according to what impacts them from elsewhere, e.g. the insurance and hospital guidelines, acts of God, etc… Dutch and I became one in our purpose and we worked together to shift the Harley clutch. Throughout the surgery recover process, Dutch was a model patient: he always took medical advice and was compliant:a trait not always present with motorcyclists. Plastic surgery as a species is a specialty most responsive to the patients request. The plastic surgeons give the highest priority of all specialties to what the patient desires. This is related to the fact that plastic surgery was the first specialty to go abroad to developing countries to repair cleft lips, which means a great deal to the patient’s body image.
The tissue was shifted from abdomen to his hand and it fit nicely into the first webspace: the area between the thumb and the index ray that had been amputated. The flap thus provided additional coverage in that webspace. This was all avant-garde surgery technique for the three of us, and it was exciting for all of us to work on the project (Milhoan, Gonzales, and Laub). And of course, we all became fast friends.
[The job of going to the metal supply store the next morning and obtaining the malleable copper wire was assigned to the lowest on the totem pole, myself. Visual, courtesy of Donald R. Laub M.D. Jr.]
We placed bone grafts for stability of the hand and wrist bones; they healed on schedule and became solid. It was a joyous day when Dutch showed up at the clinic in San Mateo for a post-rehabilitation follow-up riding his Harley. He invited me to sit on the rear seat as he drove around the block, shifting gears repeatedly and freely using the left hand for the clutch (you pull a bar in with your grasp using the left hand and fingers). We circled the block several times and it was great fun: a triumphant day for the both of us. The pleasing of the patient mandate stems from the practice of aesthetic or cosmetic surgery. The patient sets the agenda first, then the surgeon tries to formulate a plan to please the patient’s desire. The compensation from the patient lies partly in the satisfaction perceived from within the patient. In a way we work more for the patient’s benefit, and less for our own.
I used this case to present the technique at a national hand surgery meeting, as well as on my examination by the American Board Surgery for certification as a plastic surgeon. It was one of the cases I showed the more experienced big boys in the field of reconstructive surgery. It was also an example of Dr. Chase’s dream and vision of forming a new surgery specialty called “rehabilitation surgery.” And this is what we called ourselves those days, even though we later reverted to “plastic and reconstructive surgery” for the sake of compliance with the general fellowship of plastic surgeons.
Dutch was strong, independent, a provider, in control of his environment and world, and he was an archetypal American. He had good humor and was always cheerful when possible. he lived out in the redwoods near the Pacific Ocean and seemed bigger than life. He died as had been scheduled over 1000 years ago by the Almighty master planner, in an accident in a mercury mine in Mendocino County, a victim of a cave-in. What could have been better for such a hero?
Years later, his widow came to me and asked me to help her transfer some of Dutch’s wisdom and good qualities to their daughter, who would benefit if her father were alive. I promised that I would write a book.
Before he died, Dutch brought on of his prized trophies, which he had won in a motorcycle race. It was of a silver motorcycle and rider with his hand on the left side on the handlebar, shifting the Harley clutch. I kept it on my desk for 12 years.
 This is similar to the letter of intention (LOI) entered between two countries.
II. The Murder of Shep Nuland
If you count the attempted murder of Sherwin B. Nuland (Shep) as a negative, and an incident unrelated to anything bigger, you had better reconsider. Thornton Wilder in his wildly successful novella asks us to think it over. He comments that it is the place of the author not to lay down his or her own opinion and that therefore you should adopt his or her point of view; no. He feels that the author should pose the question, lay out both sides of an issue and ask you, the reader, to form your own opinion. I, though not a great author, take Wilder’s cue; I do not intend to ever say “should” or “ought to.” In the case of Shep doing a “bad thing,” we have to think in the mode of T.W. – to consider all sides. He was a successful product of the American educational and medical systems. Let us also consider for a moment that these systems were a sort of “slave” system and Shep had little choice/free will.
The coincidences involved in the horror of the unsuccessful murder of Shep Nuland in room 509 of “Ward” Tompkins-V (5th Floor), Grace New Haven General Hospital, New Haven, Connecticut, 21 October 1963, 8:15 AM, are that Jean Courtney and Nick Passerelli, slightly more senior slaves to myself in the slave labor system, Dick Cleveland, as well as Sherwin (Shep) Nuland were simultaneously present. That the event that took place made very significant inspiration for the course of several of these lives is a rare coincidence, but almost precisely homologous to the events portrayed in Thornton Wilder’s book, “The Bridge at San Luis Rey.” In this non-fictional-like book, the bridge is an Incan masterpiece made of rope, stretching across a deep gorge in the Andes Mountains of Peru, carrying in that coincidence 5 disparate persons with 5 distinct stories; the story of each life culminating at the moment the ropes broke spontaneously in a peak incident. Built in the 1300’s; given it was used, but why did it break just then? Thorton Wilder proposes the question: was a greater power in charge of the overall planning? Has it been from the beginning of time? Perhaps it was the proper ending for each life. But (I say now) some good happens in everything bad, and perhaps something good happened to each person in room 509.
Each life came together in a culmination of the many factors of life, not collectively were Dick Cleveland, Shep Nuland, Laub and the lives of all his future trainees. These lives were profoundly altered. I, for one, was given the chance to become trained in the manner of my great heroes – Professors Major, Wheelen, Roy Cohn, Robert Chase; D-2 was given that learning in turn as were 52 future residents. These last five professors experienced situations which provided them with huge, huge numbers of large and difficult cases of advanced human medical pathology. This gave them the opportunity to become usually gifted not only in psychomotor technique of surgery, but also in the street smarts of surgical experience: how to profit from tough cases, and how to profit from mistakes. Each mistake is an opportunity by which to improve yourself for the next case. This was suddenly able to be passed on to me and my trainees.
With Dr. Sherwin B. Nuland, we appreciate that he perhaps attained the highest personal achievement of any mortal man, any living person on Earth, in regard to intelligence. But in regard to helping the other person, he was neither truly gifted nor blessed. Hippocrates was wise to include in his mandate the use of both the left and right brain, instructing us to attain a skill a science, and then apply it for the benefit of the other person. When these directions are followed, and your skill and science is used to benefit another, psychic income is gained. There is not mean to be a lot of stress in this equation. However, the actions of Shep and Co. point to a state of stress, and perhaps they did not fulfill that section of Hippocrates’s mandate. Yes, Shep helped patients. Of course he did, but did he help his professional children? Certainly it was not obvious nor was it clearly accomplished as we tell this story: the answer appeared to be certainly not in the short-term. Dick Cleveland, Ray Bopp, and Kris Durham, on the other hand, were scarred psychologically, perhaps even in the long-term. But he helped me in huge proportion, but unbeknownst to either of us. I take a part of him with me now. I am better off because of him. Shep, you helped me in my whole life. Thank you, old friend.
Now, let us reflect on those who gained in huge ways by the horror of that morning in Tomkins-V, room 505, pediatric ward for surgery patients. It was a private room, the first room across from the nursing station, and was also the first room we visited each morning on rounds. We, the entourage, each had sparking white starched lab coats with embroidered name on the front left pocket, brushed hair, all of the medium length (from the hospital basement barber shop), white “company” shoes coated with paint-like polish. Each of us had an overdeveloped cerebral system, trained and molded and force-fed with courses and education of all types in all special situations and with special opportunities galore, with varied life experiences, albeit for only about 25 years for the interns and 32 years for the chief residents. Allow me, my dear reader, to share my stream of consciousness on the subject of medical education before we get to the attempted murder.
The genetics of this East Coast system for training in medicine was derived from several ancestors. The seven ancestral cultures being: (1) the Geheimrodt system e.g. Prof Gustaf Lindskog, Chief of Surgery at Yale, (2) Hippocrates’s philosophy, (3) the Guild system, (4) Buddhist philosophy, (5) the Shaman leaders, (6) Communism and Socialism, and (7) the ritual and rigors of the human dissection laboratory, e.g. Dr. Hiram Benjamin.
The Geheimrat system was characterized by the top surgeon, a genuine professor characterized with extreme strictness. No rule was ever to be broken or even thought about being broken. We joked in our hospital, “the boss is using Geheimrat discipline.” Of all the systems listed , Shep was most closely aligned with, and victimized by, this system. When visiting the Ancient revered Charité Hospital in Communist Berlin, the statue of the Geheimrat surgeon was there along with Dupuytren and Langham. Awful. In the Guild system, the training is indentured. For years, the trainee is like a slave doing all the duty work. For 5 years, the trainee cleans the floor, and in the last year they learn the actual nuances of the trade. At the last part of the service, the nuances of the discipline (e.g. shoemaker) are leaked out. The trainee is then legally able to change the public sign and the description. The metal sign is able to be hung outside. Leaders in the Shaman system have a similar relationship as the leaders in the Guild system of the Middle Ages. In any slave system there is recognition that the price for eventual freedom is 1) hard, hard, hard work, and 2) giving up your free will in decision making, temporarily.
The cultural richness of this crew was intensified by the “diversity” of our previous lives, but held ever-so-tightly together in a union by bonds that no one ever conceived of renting asunder. We were all the same, the sameness arising from our quest to be successful for ourselves in the pyramidal training system, which would eliminate along the way fourteen of the sixteen interns. The trick of success in the pyramidal training system was to conduct yourself not at the expense of others, but to actually help others along the way; that is, don’t step on anyone on the way up the ladder. Conduct yourself at psychological level 7 (q.v.).
One night we had operated on a patient for bleeding ulcer at the private pavilion which was built next to the main university hospital, connected by an underground corridor. Fearing the patient would go into shock, being hypovolemic and having lost a lot for blood during the operation, he was reluctant to move the patient from the operating table unless it was done without any jolting. The orderlies were all off duty for the night. He therefore called in Dick Cleveland, a fellow intern, not of the same mold as the rest of us because he had been in the Navy for a few years and was hardened to the ways of the world and to the ways that exploitation of others might not help a person get ahead. So when he was called in on the third night after being on duty and getting an hour’s sleep for each of two nights in a row, he was grumpy. Shep called him in to help lift the patient from the operating table to the gurney. That would be all. Then he could go back to sleep.
The next morning Dick Cleveland and I, Bernie Siegal, and Shep were making rounds at this first room. On seeing the first patient, Shep began to rattle off in the manner he had rattled off to Ray Bopp (q.v. Ray Bopp incident, where Ray had to stay in the hospital fourteen days in a row to complete the work on his charts). Again, it was one thing after the other. “The IV has come out, Dick. Why didn’t you get here sooner to put it back in? You know you should start the IVs quickly and not let the patient [a child] become dehydrated. What’s the result of the chest film? Have you taken the EKG? There’s a culture and sensitivity on his would – what is it? The child’s hematocrit is what? 35? I think you’re lying, Dick. It looks more like 40.”
“No, Shep, it’s 35.”
“The temperature of this child is what? Are you up to date on the input and output? If it isn’t right, you have to weigh the patient. Get the scale, now!” This was a big scale, a dead scale, something to lie on rather than stand on. As these orders were being barked off to Dick, you could tell he didn’t like it, but he couldn’t talk back because that would mean his entire career, his entire thirty years of night-and-day work would have been down the drain. He couldn’t mouth off, and it was tough to keep saying, “Yes sir.” There was a red glow lighting up his face and then his neck, and the veins on his neck were beginning to bulge. His hands were clenched into fists and he began to have a tremor in his arms, shoulders, and hands. Finally he could stand it no longer and suddenly he broke. He pounced just like a cougar on his prey.
He pushed Shep Nuland against the wooden door, put both hands tightly around the base of Nuland’s neck, then snapped Nuland’s head back against the door with a tremendous sound of “bonk,” and then there was a reverberation, “bonkity bonk bonk,” as the door continued to bounce, he pulled Shep’s head forward and snapped it back again, and then on the third slam against the wooden door he said, “I’m going to kill you! I’m going to kill you! I’m going to kill you!” And each of us hated Shep so much at that point that we were secretly agreeing with Cleveland acting out and sort of pretended we didn’t know what was going on. We were looking under the bed or down the hall or going for bandages – – something to avoid having to save Shep form his dilemma. Finally Bernie Siegal, the senior assistant resident, came and pulled Dick Cleveland off. Cleveland was not a small man, and neither was Shep. Both were pretty surprised at what had happened. Later that day Cleveland was called down to the offices of the Chief of Surgery, Gustav Rindskog, and was chastised and prohibited form being on any service that Shep would be on ever again.
To fill in that service, they called me and asked if I would be kind enough to fill in the next two general surgery rotations in place of Cleveland. And I acceded to that. I had been chosen because of the testicle incident where I showed my intelligence, and the incident of the prefrontal lobectomy knowledge (q.v. these stories separately). I was chosen also because I continued my competitive habit of working just a little harder than anyone else – I was skimmed from the top of the pyramid. I got two rotations in upstate Connecticut, in Willamantic, the home of American Thread Company, where Drs. Whalan and Whelan and Major were the attendings, private doctors, wonderful, affable, completely developed human beings who allowed you to do the surgery after reporting the cognitive aspect to them: the literature, the possible complications, the plan B, ion there words, what were the precursors to my “yellow sheet,” and invited you to their homes and their parties. These were the opening events of my career.
 My son, Donald Laub Jr., ___ (add titles)
 Geheimrat served as an honorary title to those with outstanding contributions to medicine, and is now no longer in use.