Thursday, June 29, 2017

2011: Hip Replacement & Bladder Cancer!

Panama Canal & Medical Science!


As Hip replacement hit the news again, here is my reprint:

  
Panama Canal © 2008 Am Ang Zhang

Most people probably know about the French failure to build the Panama Canal. Many thought that this was due to yellow fever and malaria which were diseases thought to be due to some toxic fume from exposed soil.

In 1879, Ferdinand Marie de Lesseps, with the success he had with the construction of the Suez Canal in Egypt just ten years earlier, proposed a sea level canal through Panama. He was no engineer but a career politician and he rejected outright what the chief engineer for the French Department of Bridges and Highways, Baron Godin de Lépinay proposed, a lock canal.

The engineer was no match for a career politician:

“There was no question that a sea level canal was the correct type of canal to build and no question at all that Panama was the best and only place to build it. Any problems – and, of course, there would be some - would resolve themselves, as they had at Suez.”

“The resolution passed with 74 in favor and 8 opposed. The ‘no’ votes included de Lépinay and Alexandre Gustave Eiffel. Thirty-eight Committee members were absent and 16, including Ammen and Menocal, abstained. The predominantly French ‘yea’ votes did not include any of the five delegates from the French Society of Engineers. Of the 74 voting in favor, only 19 were engineers and of those, only one, Pedro Sosa of Panama, had ever been in Central America.”

The French failed in a spectacular fashion.

Diseases like yellow fever and malaria played their part as a sea level canal involves a good deal more digging.

The discovery of yellow fever being carried by mosquito must be credited to one Cuban physician:Carlos J. Finlay.

For twenty years of his professional life, he stood at the center of a vigorously debated medical controversy: the etiology of yellow fever. Finlay believed that it was waterborne and carried by common mosquitoes: Stegomyia fasciata.

Finlay's advice and experiences proved invaluable to the United States Army Yellow Fever Commission. When the Commission decided to test the mosquito theory, Finlay provided the mosquitoes andWalter Reed of the Commission wrote triumphantly after the success of the experiments of inducing yellow fever by mosquito bites, ‘The case is a beautiful one, and will be seen by the Board of Havana Experts, to-day, all of whom, except Finlay, consider the theory a wild one!’ The US experiments vindicated Finlay's two-decade-long struggle.

Reed acknowledged that ‘it was Finlay's theory, & he deserves much for having suggested it.’

William Crawford Gorgas wrote of Finlay:

"His reasoning for selecting the Stegomyia as the bearer of yellow fever is the best piece of logical reasoning that can be found in medicine anywhere."

The discovery by Major Ronald Ross that malaria was transmitted by mosquitoes (Anopheles)had tremendous impact on the Panama Canal. 

Crude oil was used on stagnant water to prevent the mosquito proliferation and nets were used to protect workers. Quinine was extensively used to treat malaria. A lock canal was eventually built by the Americans. 

Some say that a large part of the eventual success on the part of the United States in building a canal at Panama came from avoiding the mistakes of the French. Knowing the causes of diseases must have helped.

David McCullough in his book "The Path Between the Seas" wrote: "The fifty miles between the oceans were among the hardest ever won by human effort and ingenuity, and no statistics on tonnage or tolls can begin to convey the grandeur of what was accomplished………It is a work of civilization."

Links
  
  

There are things in medicine that we knew nothing about and often we are surprised at how some very basic scientific principle is behind some apparently strange conditions.



Panama reminds me of my friends visit. I have not seen him for years as we went our separate ways as he children were growing up. He was a sporty person and played rugby to a professional level. Here is the blog:


Tribolgy: One Patient, One Disease.

Wednesday, July 27, 2011


© Am Ang Zhang 2011
Did you enjoy your Cruise?

Sure!

So you can get away from blogging and from Medicine.

I got away from blogging but then it was only the slowness of the Internet that was prohibitive.

Then I realised that perhaps we doctors never could get away from medicine and in a sense I did not want to either.

Medicine has become a hobby.

Cruising is an interesting way to have a holiday, you do not have to pack everyday and you get to meet some really interesting people.

On our Cruise we had dinner with an eminent professor and his wife.

Tribology!!!

Yes, a world class Medical Engineer and all I might want to know about hip and knee replacements.

Wow!

A friend came to our tropical resort to play golf with me. 

He was walking a bit funny on the golf course.

“I used to hit 280 yds.”

“What happened”. He now hits 160 yds if he is lucky.

“Bilateral hip replacements.”

Good old rugby.

But that was not all. A year before he had bladder cancer that was diagnosed and luckily it was caught early.

“It was painful but the BCG treatment was good!”

So perhaps my professor was wrong: one patient one disease.

He obviously had hip problems from rugby and then bladder cancer.

So I asked my new found friend.

“There is a theoretical risk as the cobalt in the alloy in particular could be a problem. Check out the Swedish research.”

I told him about my friend and my professor.

“Interesting approach!”

“I know. But it concentrates the mind.”

Lisa B. Signorello et al

In summary, overall cancer risk among hip implant patients was close to expectation. However, we observed these patients to have a statistically significant excess of melanoma and prostate cancer and, after a latency of 15 years or more, of multiple myeloma and bladder cancer.

In contrast, we noted a statistically significant deficit of stomach cancer and suggestive evidence for decreased colorectal cancer risk. The incidence of bone and connective tissue cancers was not statistically significantly higher than expected for either sex in any follow-up period.

Further evidence suggesting an antibiotic effect  comes from a study in Denmark (14),   where a lowered risk of stomach cancer was found among patients with osteoarthritis who underwent hip implant surgery (presumably exposed to both NSAIDs and antibiotics) but not among those who did not have surgery (presumably exposed only to NSAIDs).

However, because this investigation provided the first opportunity to adequately evaluate the long term cancer-related effects of hip implants, the associations that we observed with bladder cancer and multiple myeloma, while also potentially attributable to chance or bias, should be considered carefully and require further in-depth study.

 J Natl Cancer Inst 2001;93:1405–10


A year later my friend called me:

"But Cockroach Catcher, you wrote about it in July of last year! Some even had bladder cancer!"

I suppose Medicine is still of great interest to me and one should never accept what is known now as the whole truth. Medicine cannot stagnate nor should we forget basic principles. 

The Telegraph:

One of the participants in the trial, David Jose, 51, from Clifton, near Bristol, had a hip "resurfacing" operation in 2007, a year before retiring as a police officer.

The father of two had been suffering hip pain from playing football and rugby.
In May last year he was told that the tests had found atypical cells which were not at this stage cancerous.

He saw Angus Maclean, an orthopaedic surgeon at Southmead Hospital involved in the study, who said that the trial had established three cases in which patients had developed bladder cancer, and 14 more including Mr Jose who had changes to their chromosomes.

The doctor told him researchers "could not believe" what had been found, describing the findings as "shocking".

Not as shocked as my friend.

Feb 4, 2012

Tribology: Hip Replacement & Cancer


My golfing friend wrote to me asking if I have read the latest in The
Telegraph.

"But Cockroach Catcher, you wrote about it in July of last year! Some even had bladder cancer!"

I suppose Medicine is still of great interest to me and one should never accept what is known now as the whole truth. Medicine cannot stagnate nor should we forget basic principles. 

To remember our eminent yet formidable Professor of Medicine, Professor MacFadzean: One Patient One Disease.
I would like to pay tribute to our eminent yet formidable Professor of Medicine, Professor MacFadzean, 'Old Mac' as he was 'affectionately' known by us. He taught us two important things right from the start:

First - One patient, one disease. It is useful to assume that a patient is suffering from a single disease, and that the different manifestations all spring from the same basic disease.

Second - Never say never. One must never be too definitive in matters of prognosis. What if one is wrong?

Mysterious Psychosis: One Patient One Disease


Teratoma: An Extract,

Wednesday, June 28, 2017

Norway & Hong Kong: Drunk Or Art Nouveau!


Democracy Or Alcohol?



Ålesund ©2012 Am Ang Zhang

In 1904 fire destroyed most of Ålesund.

It was rebuilt in Art Nouveau style and is arguably the most beautiful city in Norway without the City Hall.

Democracy: Voted against joining EU in 1972 and 1994.


Norway is one of the richest and most contented nations on earth, with a GDP per capita of £40,000 – compared to £23,000 in the UK, and an EU average of £21,150.
Unemployment is at 3.25 per cent, while GDP is growing at 2.75 per cent per year – as it has on average over the last 40 years.

It also regularly tops the UN's survey of quality of life, with a generous welfare system – women receive 46 weeks maternity leave at full salary, compared to Britain's six weeks on 90 per cent – and free education (incl. universities) is provided for all.

The country funds this through its huge reserves of oil, timber and fish which it manages prudently, stashing away large percentages of its oil revenues to fund the future healthcare needs of an ageing population.

Alcohol:


Do we ever learn that prohibition never did anything to alcohol consumption nor would price control? 


With the millions spent on Cocaine in Wall Street and The City, when will we wake up to the fact that these are Tax Free perks?




©2013 Am Ang Zhang

By Wendy Leung - February 27, 2008 05:37 EST
In a place without democracy!

Feb. 27 (Bloomberg) -- Hong Kong's government abolished taxes on wine and beer after posting a record surplus, boosting efforts to turn the city into a wine-trading hub.

The tariffs will be abolished immediately, costing the city government HK$560 million ($72 million) in annual tax revenue.
Tax was 80% before 2007 then 40%


The rest of Hong Kong Tax:
No sales tax
No capital gains tax
No VAT
Maximum salary tax of 20%
Profit tax maximum of 16%
Inheritance tax or estate duty has been abolished since             11February 2006. 

Yet, my doctor friends told me that there is no binge drinking problem like they have in Norway where there is high taxation and much difficulty in buying alcohol.

Strange: A drink too many!

Ålesund Norway©2012 Am Ang Zhang





Solveig Torvik 
December 16, 2010 

Weekend binge drinking is a perplexing feature of Norwegian cultural life to many visitors.

The role of alcohol in Norway often appears to be to consume it until you’re senseless, and alcohol commonly is accepted as an excuse for indulging in antisocial behavior. Binge drinking seemingly isn’t regarded as aberrant behavior in Norway, even by sober citizens who, generally speaking, uncomplainingly tolerate the ensuing brawls and other unpleasant results.

But why do so many people who do live in the “world’s best place” drink until they’re comatose? And why are many of them prone to violence and aggression when drunk? No one knows.

Dr Ole Johan Hoyberg, formerly a hospital-based psychiatrist in Ålesund, told newspaper Sunnmørsposten: “There’s a great deal more drunkenness in the communities that I got an insight about as a hospital doctor. Alcohol abuse is on the point of becoming a national sickness.”

Which seems an odd state of affairs indeed for a nation that’s billed as the world’s best place to live.

Perhaps no tax on alcohol beats democracy!


Monday, June 26, 2017

Mahler: Sadness & Pleasure Principle


©2016 Am Ang Zhang


Farewell                      Wang Wei (701-761)
Dismounting, let me share your farewell wine  
Where, friend are you heading now?
Choking, fate has not been kind to me
Will retire to the southern slopes to seek rest
Enquire no more when I am gone 
Till the end of clouds, endless white clouds!

Pleasure Principle:


Sigmund Freud’s Pleasure Principle is well known, but his other small “contribution” to mankind, i.e. his unofficial discovery of Cocaine, is probably less so. He in fact became quite an enthusiastic user of cocaine, in addition to smoking a large quantity of cigars, up to 20 a day. He developed jaw cancer and had to endure 33 operations and eventually died of it. 
I am not here to encourage the use of cocaine or cigars (as if people who used them needed encouragement). 
Instead I am going to talk about some of my pleasure pursuits. I have from an early age been interested in music though I have never played any instrument except the “gramophone” if you can call it an instrument. It can also be said that I play these instruments by “proxy” through my children. I have always had a multitude of hobbies: photography, electronics (I built my own radios and valve amplifiers), and snorkeling to name a few. Arriving in London in the early 70s allowed for easy access to France and French wine and food remains one of my most pleasurable pursuits, though my interest in wines has now been extended to Port and other non-French wines. 


Sadness

In life one goes through difficult times and we Chinese are fairly philosophical about it – unhappiness is often viewed as something secondary to external circumstances such as loss and bereavement, political injustice (which has afflicted most of our families) and other life events that are beyond our control. Our classical poets wrote about such sadness and generally accepted what life befell them. 

When life events do not go our way, some turn to religion, although more and more people nowadays turn to the “happy pill” (drugs). One can also seek comfort in Music, Poetry, Photography, Writing (and blogging), Painting, Fishing, Knitting, Travel and of course Food and Wine. 

In an age when people sought happiness in all ways possible we need to remind ourselves that sadness has been the driving force behind many writers and composers.

Mahler wrote Kindertotenlieder to five poems written by Rückert. Rückert wrote 428 poems following the death of his two children from Scarlet Fever. 

Mahler lived in an age when bacteriology was very much in its infancy. There was still little understanding of the role Streptococcus played in a range of illnesses from Scarlet Fever to Rheumatic Heart Disease and Radium was often used to treat Streptococcal related conditions.  

Mahler’s own daughter tragically died from Scarlet Fever four years after writing Kindertotenlieder and Mahler himself contracted Rheumatic heart disease. When there was still little understanding of the etiology of diseases, superstition came into play so much so that Mahler did not want to write a ninth symphony. It was the start of the Curse of the Ninth Symphony.

Das Lied von der Erde was indeed the result as it was composed after his Eighth Symphony and he did not want to name it his Ninth. 

Mahler conceived the work in 1908 when he was already unwell with his heart condition. A volume of ancient Chinese poetry under the title of The Chinese Flute (Chinesische Flöte) repoetized by Hans Bethge was published in German and Mahler was very much taken by the vision of earthly beauty expressed in these verses. Fate he felt has been unkind to him but he felt able to accept it in his own fashion.

                                                          

Mahler died on May 18th 1911 in Vienna.

"I think it is probably the most personal composition I have created thus far."    Gustav Mahler

The first performance of Das Lied von der Erde was conducted by Bruno Walter after Mahler's death. 

Bruno Walter described it as: "the most personal utterance among Mahler's creations, and perhaps in all music."

My first encounter was in the early 70s with the recording by Janet Baker and Waldemar Kmentt (with Kubelik conducting the Bavarian Radio Symphony Orchestra). I still think it is one of the very best performances of Das Lied von der Erde.

Tuesday, June 20, 2017

Oporto & Hippocratic Past: Do No Harm!


We were in Oporto last summer and in this beautiful place famous for its Port, I stumbled upon a museum that reminded me of our Hippocratic Past. 



It was the medical museum right in the middle of Oporto. 



The following is extracted from The Cockroach CatcherChapter 30  Religious Fanaticism



I
n our work we have some unusual referrals now and again and sometimes they require unusual handling.
         I had an urgent call to deal with a serious suicide attempt at a well known local boarding school.
         No, the child was not admitted to hospital as would be the usual practice, but was kept at the infirmary at the school instead. I arranged to make an immediate visit to see her there.  She was only twelve.
         This was one of the few Church Schools that catered for able children who could not afford expensive private schools. Part of the intake were bright children of church personnel from all over the country. It still had rather medieval costumes for uniform and you could spot the school children a mile away with their long dark blue gowns. Boys and girls had the same outer costumes, but different belts and buckles according to the pupil's year group.
         The school had the feel of a monastery and was quite overpowering as you entered. Individual boarding houses lined up neatly. It read: “We mean business. You are here to learn.”
         The infirmary was even more imposing. It was part of the main block. The main door as you could imagine was at least 15 ft tall and weighed a ton.  The old wrought iron handle had seen a few centuries of use and yet its hinges were well oiled so that when the matron greeted me, she had no problem opening it and it did not produce the squeak I expected.
         The dark double height ceiling made darker by a few centuries of candle and oil smoke would make you think twice before falling ill.  I was led through a couple of archways before I reached the infirmary. There were glass cabinets with all kinds of ancient medical equipments. I was once fortunate enough to archive by photo the small museum at our psychiatric hospital and had since been interested in ancient medical tools. This place seemed to have more and one wondered what they used those tools for. Then I realised that this was a hospital before it became a school, and during the war it was a military hospital.
         At least I am in good company today, I thought, and I had better not let down my colleagues from the Hippocratic past.
         It was early March and spring had not quite arrived in southern England that year. There was not much light coming through the small oval windows. Matron seemed to have read my mind.
         “This was not in fact a proper hospital ward as the main hospital buildings are now the dormitory. This was the staff chapel, but as we all now use the main chapel, it seems such a good idea to turn this into an infirmary. Very good for migraines and headaches and that is normally what we deal with.” Matron said.
         I thought - mmmmm, neither condition can be confirmed by any medical investigation.
         Still it was quite a big room and with the neatly made beds and their white sheets, was speaking loudly – this is an infirmary; you are here to be ill and hopefully to recover.
         Ruth was sitting in one of the middle beds and with her nurse.
         “We have kept a nurse with her since last night, doctor.” Matron assured me.
         There we were, a rather petite looking girl in her hospital outfit sitting on the rather high bed trying to read.  She had a small face and as I approached, slipped off the bed and stood to attention. That said a lot about what kind of school this was. She was reading a French novel but I could not really tell which one it was. She looked cheerful, certainly too cheerful for someone who had tried to get to the other side less than twelve hours ago.
         It was a job to persuade matron to let me speak to Ruth on my own. When she realised that I meant what I said she sent the nurse to sit outside the door just in case and still hoped that I would let her keep it ajar an inch or so. She eventually agreed to have it closed but the nurse would just be outside.
         Ruth herself was not too bothered and I suspected that when you lived in a big dormitory, privacy was not a big concern.
         It was not my style to jump straight to what happened. This disappointed her a bit.
         “Don’t you want to know what happened?” she asked.
         But she agreed to do it my way and in fact it was a better idea, she later agreed.  She thought I was going to ask about the night before and then send her to a mental institution.
         Matron had informed the parents of my visit and mother, who was a social worker, was driving up from the coast and hoped to meet me within the hour.
         There is a very simple rule when we assess attempted suicide. We have to decide if this is the usual or the unusual.
         The usual – probably late teenage, made up to look twenty one, argument with boyfriend, got drunk and took eighteen Paracetamol or whatever was handy including the rest of the month’s pill. Most survived but now and again they were unlucky, were found too late and died a rather painful death. I was lucky – I never had to deal with those. I heard of one though, but she was dead when found. She left mum a note but mum was out with her boyfriend all night and the next day she came home to find a dead girl. Luckily these cases were rare and for that we had to thank our lucky stars. The virtual disappearance of barbiturates and tricyclic antidepressants meant that we had to deal with fewer accidental deaths, though Paracetamol remained the most potent killing agent.
         This girl was not like the usual. She tried to hang herself with the very belt with which she was meant to tie her cloak. Luckily for her the light to which she tied the belt did not hold her weight and she fell to her bed and tripped out the mains. Most of the other girls were asleep but her best friend saw her. She was too scared to say anything at first but now she could not stop crying and had been kept in her own dorm away from my patient’s influence.
         She was one of the star pupils of her year. Her father was the chaplain at a church near the coast. She was the only child. She was also a very good swimmer and represented the school in competitions. She was very talkative and despite what happened was quite at ease telling me about herself and her views of life.
         For three nights before going to sleep she heard a voice telling her to hang herself.  The previous night she actually saw a shadow telling her she must do it to keep her parents from harm. She thought it would not matter as her parents were more important.
         I did not think she was making it up. She did try to hang herself.
         What should I do?  Was this the start of a psychotic illness? Did she have a fast growing brain tumour?  If I made the wrong decision, she might end up dead one way or another.
         No, there was no other sign of either a depressive illness or psychosis. Why were the parents not here for something so serious? Why was mother still at work? Why was father not on his way here? Perhaps they did not take this seriously and maybe I should not either.
         This was an otherwise well put together girl, clever, good looking and had a good prospect of achieving well.
         Would this be someone you put on an antidepressant or antipsychotic?  Would I need to send her to a mental institution?
         One of the most important things we learned in medicine is: when in doubt, do nothing.
         To be more precise, do not do anything that is not reversible. What was the rush?
         I had for years an arrangement to admit my patients, if necessary, to our paediatric ward which normally took in tonsils and dental patients. The hot cases were appendicitis, and then there were my patients who did not require psychiatric inpatient treatment; they had mostly been anorectic patients who, incidentally, had done well over the years. They were often there without other anorectics and that was perhaps one of the reasons they did well.
         A number of O/Ds (overdoses) used to go through the paediatricians, and I would be consulted before any of them could be discharged – a sort of safety valve approach. There were no seriously ill patients. The nurses were a fairly stable group.  It was an ideal place for mothers returning to a nursing career. Over the years, they had got to like my special group of patients, including infants with a sleep problem.
         That would be the ideal place for Ruth. It was a modern hospital. And we could observe her. Like they say, something is going to give.
         Mother turned up. She did look like a social worker. She explained that if this was a hysterical gesture she did not want the girl to think that she could do something like this and get her attention.
         But that was not how I saw it. No, this was no textbook case.
         It was very interesting talking to mother. Half the time I was talking to a colleague and the other half to a very frustrated modern woman married to a very strictly religious man.
         She and her husband were at college together. They were idealists. They were CND members. They marched against this war and that and eventually he studied theology and she, social work. Ruth was a perfect baby, bright and cheerful. She was their only child. She obeyed all rules and she was diligent.  She was every mother’s dream. She was cute, charming, clever and full of life, never demanding in any way and had always been the top achiever in everything she did, academic or sport. She had quite a following in school and what happened came as a shock, and a serious shock to a boarding school.
         A religious boarding school.
         Such behaviour could be infectious and more so when a natural leader did it.
         This is particularly true of psychiatric patients and more so adolescents in an institution. Some years ago a colleague’s two daughters sadly committed suicide one after another in a boarding school.
         I had to come up with a solution.
         A friend once said to me, “You often have to do certain things when a patient is referred to you, not because it is necessary for the patient, but because it is important for the referrer, the parents or the people around the patient.”
         I could not leave Ruth in the boarding school. I could not send her to a mental institution. So I had to admit her to the paediatric ward.
         Mother agreed. Matron was most relieved. Ruth of course would not object. I felt happier getting her out of that rather imposing place.
         An MRI did not reveal any lurking growth and you would be surprised how many parents would have been disappointed with that. Luckily not this mother.
         Ruth became extremely helpful on the ward assisting with the younger kids distressed by their ops and she would be patiently reading them stories. Schoolwork was sent in regularly and I did not think she suffered much from being absent.
         Visiting was rather restricted, not by the hospital but by the school for obvious fear of contamination, contamination of the minds of the innocent ones.
         She soon revealed the figure she saw was that of her father. She said she was afraid to tell me before.
         Now I understood the reasons I never once saw father. 
         She told me that over an extended period of time she would be shut in with him in an under-stairway cupboard when he would recount biblical passages of hell and damnation. The idea was to give her a real taste of hell. 
         “Why was it necessary?” I wondered to myself, “Why do this to a girl who by all standards is perfect?”
         I wish I knew and I wish I had made up the story. But real life could be very strange indeed.
         With her permission, I brought mother in and she started crying when Ruth said, “I told him.”
         Mother assured me later that she did not think there was any sex abuse but it did cross her mind that all the dramatic teaching of Revelation might have something to do with her daughter’s hearing voices and especially those of her father.
         At that time I had just come back from Peru, with images of Juanita[1] still fresh in my mind.  The tribal rituals of virgin sacrifice in the Andes, visions and religious fanaticism suddenly took on a new meaning.
         She respected her father and what he said had to be done, even if it was hallucination.  Sacrifice would be nothing and if she was to go to heaven anyway, she would have avoided the torture of hell.
         I continued to see her and her mother. We seldom talked about religious matters, but more about studies, literature, sport and current affairs. Father never came to any of the appointments.  I did not force him to come to see me. I believe it was sometimes more revealing to let things unfold. Often things that did not happen told a story too.
         There were two more sightings of the devil but she was not distressed.
         I never pronounced any judgment on the origin of her symptoms and school soon gave up asking me. There was an unspoken understanding with Ruth and mother and I preferred to leave it that way. I felt that my job was not to destroy but to help recovery.
         Was it ethical? Could I have missed what is called Satanic Abuse? We do know what happened to some of those who were so sure of their views of abuse. How much harm was caused? How many children were wrongfully taken away never to return to their parents?
         Of course doctors could be wrong and of course my views might change in time but for now things were working out. 
         Bad parents are generally easier to deal with. It is easier for children to know from early on that they are better off not taking any notice of them and they will, at least the resilient ones will, survive. Many children of psychotic parents become independent and tough from an early age. “Good parents”, on the other hand, are more difficult to handle and if they already have a position in society, what are the poor children supposed to do?
         Ruth had been sheltered in her upbringing. She was not streetwise and staying in a highly religious institution, she did not have the chance to mix with any rebellious children.
         As a first born, she followed rules and orders.
         I continued to see them.  Later, without any direct instruction by me, mother worked out that it would be better to move her from her current school to another church school. This one was less austere and the focus was more on education than on religion. She blossomed and now as she was not boarding, she began to go out and meet boys. Soon enough she was dating a boy. With mother’s help they kept this from father whom I still had not met. She achieved some exceptional GCSE results, moved on to a state sixth form college which her now boyfriend also attended. He wanted to be an engineer and she was aiming for languages.
         She went on the pill and father still had no idea she had this boyfriend.
         Her A Level results were straight A's and she got her place at a top university. She came to see me during the Christmas break.  She settled in very well and was enjoying her course.  I did not ask her about her hallucinations. Sometimes we need to know what not to say.
         Mother left father as soon as Ruth got to university and continued to work as a social worker. Father was transferred to the north.
        
         Perhaps I should have raised alarms about father.
         Perhaps.
         I was lucky she came to no harm.
         Sometimes one may not be so lucky.





[1] Juanita (also known as "The Ice Maiden") was discovered on the top of Mount Ampato near Arequipa, Peru, on September 8, 1995 by Johan Reinhard. She was 12 to 14 years old when she was sacrificed and is believed to have died about 500 years ago.
    Although she was frozen in the frigid temperatures on Mount Ampato, her body was discovered because a nearby volcano had caused Ampato's snowcap to melt. The undisturbed site of her burial included many items left as offerings to the gods. Two other children's bodies were discovered near her.

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