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SMALL WONDER

Published Feb. 9, 1993|Updated Oct. 8, 2005

John W. Holter of St. Petersburg doesn't have any hifalutin professional credentials. He doesn't even have a college education.

But Holter has a gift for invention, which he applies to vexing problems doctors bring to him.

He has made an apparatus to treat cervical cancer, kidney dialysis pumps, artificial heart valves, finger tendons, even artificial bladders. His most famous creation was the first successful shunt valve for hydrocephalus, a device that has saved the lives of hundreds of thousands of people around the world over the past 37 years.

"I think it was worth the Nobel prize," said Pennsylvania neurosurgeon Eugene B. Spitz.

Holter, 76, shows the rest of us just how much a creative person can accomplish with a modicum of common sense and a lot of motivation.

His motivation was a tiny guy with big blue eyes.

Race against death

John and Mary Holter had tried for 10 years to conceive a child before they achieved their goal. Surely, they thought in November 1955, fate couldn't be so cruel as to finally grant them a son, and then take that new little life away.

But Charles Case Holter _ "Casey," to his parents _ was born with meningomyelocele, a sac on his back filled with nerve tissue and bits of spinal cord.

Surgeons can repair the sac but not its effects: permanent paralysis from the waist down. Babies with meningomyelocele also tend to have hydrocephalus, commonly called "water on the brain." Casey was afflicted both ways.

Cerebrospinal fluid, which protects the brain, is produced there. It travels through the spinal cord, back to the brain and eventually into the blood stream.

Normally there is a balance between the amount of fluid produced and the amount absorbed. But sometimes the outflow system gets blocked. When you dam a stream, you get a lake, and the same thing happens in hydrocephalus.

This can happen at any age, but it is most common in premature babies.

In an infant, the bones of the skull are not tightly knit, so with hydrocephalus the head just grows and grows. The forehead bulges, and the eyes angle downward, producing an effect called "sunset eyes."

When Casey was born, doctors didn't have a reliable way to get rid of the fluid, so each day, they took the babies to what parents called the "torture room." There they stuck a needle through the fontanel, the soft spot in the babies' heads, and withdrew enough fluid to keep them alive another day.

The babies' screams echoed down the hallway. Doctors said babies couldn't feel pain, but parents knew that was bunk. Holter ached for his son.

In February 1956, surgeons felt Casey was old enough to withstand surgery to install a shunt that would drain the excess fluid. At that time, there were as many variations in shunt surgery as there were surgeons, but nothing seemed to work very well.

The surgeons ran polyethylene tubes from the ventricles of Casey's brain to his abdomen, where the fluid would drain out and be absorbed by surrounding tissues. The trouble with this was that abdominal tissue tended to grow around the end of the polyethylene tube, clogging it up.

Surgeons knew it would be more effective to drain the fluid into the jugular vein, where it could be dispersed through the blood stream. But their efforts flopped, because whenever the child coughed or sneezed, blood backed up in the tube and clotted.

Both times the operation was tried on Casey, the shunt worked for only about 10 days.

Holter tracked down Spitz, who at the time was chief of neurosurgery at Philadelphia Children's Hospital. Spitz and Holter examined the latest shunt valve, made with a stainless steel ball and platinum spring. It tended to develop metal fatigue.

"What we really need," Spitz said, "is a new kind of valve."

"Heck, I can make that," Holter said.

Holter was a mechanic, or, as he jokingly called himself, a "knuckle-knicker." He worked for Yale and Towne, a company that made door locks, at a research lab in King-of-Prussia, Pa.

His company agreed to let him use the company's machinery. Holter set to work.

Overnight, he made a demonstration model: a thin, 3-inch-long tube of polyvinyl chloride that contained two miniature valves. They operated on the same principle as the nipple on a baby bottle: When the fluid pressure builds up, the slit in the nipple opens to let the milk flow out. As the pressure diminishes, the slit closes again. It's impossible for fluid to flow back through the slit.

Spitz told Holter the design was terrific. But where would he find a rubbery material that could withstand sterilization at 250 degrees or more? All that would be left of most plastics was a circle of goo.

Holter spent three weeks in a race with death. He called all the plastics and rubber manufacturers he could find, praying that Casey would live until he could come up with a device to save him. One day, a chemist at a tire and rubber company told him to try a new product, silicone elastomer. It was being used in the doors of high-altitude bombers because it remained stable in extreme cold.

The same held true for heat, the chemist said.

Holter found a company that processed the silicone elastomer in Phoenixville, Pa. The research director there understood the urgency and, using Holter's design, had his shop quickly mold several pieces that Holter could assemble at home.

But Casey grew weaker; it looked as though he wouldn't last. Holter begged the surgeons at Lankenau to do something, anything, to keep him alive just a few more days. So they undertook another operation to install a metal-ball valve with a polyethylene tube. This time, Casey suffered cardiac arrest on the operating table.

In those days, surgeons didn't have the sophisticated resuscitation machinery that they have now. They opened the baby's tiny chest and massaged his heart with their hands for 30 minutes until they could restore the heart beat.

He survived.

While Casey hung on, Holter worked night and day on his project. Using pipe fittings and a pressure gauge, he made a crude autoclave to test the rubbery material. When he heated it on the stove to see what happened, it remained unfazed. Holter started making valves in his garage.

Each one was just over an inch and a half long, small enough to fit behind a baby's ear. It was strong enough to last a lifetime, yet flexible enough to bend in half without any damage.

When Holter brought the valves in to the hospital for a demonstration, surgeons could hardly believe what he had accomplished.

"It was just amazing," Spitz said.

Casey, laboring for breath under an oxygen tent, was too weak to be given the precious shunt. So another child was actually first to try it out, in March 1956. It worked. In April 1956, Casey was given his father's valve. It faithfully performed its job. His head shrank from 24{ inches to 22 inches within six months.

Device's fame spreads

At that time, St. Petersburg attracted ailing children from throughout the state to the old American Legion Hospital for Crippled Children, at 22nd Avenue S and 26th Street. The hospital was inundated with hydrocephalic infants whose prognosis was grim.

In November 1956, the now-defunct Town Journal magazine profiled the family, and two months later, Reader's Digest ran a synopsis. Because Holter's parents, Charles Robert and Favian Holter, lived in St. Petersburg, the Times ran an article about the invention of the valve. One of those who read it with great interest was neurosurgeon John Thompson.

Thompson traveled to Philadelphia, watched the surgery, bought as many of Holter's valves as he could get and shipped them back to St. Petersburg, where he began implanting them. They worked like a charm.

Thompson believes Holter saved far more lives in his workshop than Thompson did in surgery.

"I'm very indebted to him. Hundreds of my patients are indebted to him," Thompson said. "He has made a major contribution to medicine."

In 1976, the University of Sheffield in England awarded Holter an honorary doctorate for the development of the shunt valve. He became the first non-medical member of the Society for Research into Hydrocephalus and Spina Bifida.

Casey never really recovered from the episode of cardiac arrest. His brain had been without sufficient oxygen so long that it was permanently damaged. He also suffered occasional convulsions. During a seizure just before his fifth birthday, he died.

But his father kept Casey's memory alive by taking the shunt valve to medical meetings in other countries, providing them free to those in need.

Today, he still commutes to Pennsylvania _ driving the 17-hour trip without stopping except for gas _ for two weeks each month. He spends the rest of his time at his waterfront home on Snell Isle, or visiting his 99-year-old mother, who is in a St. Petersburg nursing home.

Even though he has a painful back condition, he's not ready to lean back, put his feet up and rest.

He is currently scrambling to find a new source for the silicone material used in Casey's shunt. The silicone breast implant controversy has led Dow Corning to say it will discontinue manufacturing the substance. Without it, manufacturing the shunts and other crucial medical devices will be brought to a halt.

Holter says money isn't what motivates him to keep working, and there is plenty of evidence that's true. He has donated more than $600,000 to local charities in the last four years.

"I'd rather do it while I'm alive and see it do some good," he said, "rather than have an estate and have the lawyers fighting over it."

Though 76, Holter won't stop looking for innovation.

"I'm never satisfied with the way things are," he said. "There's always a better way to do it."