Sacrococcygeal teratoma (SCT)

[Pologirl]

I still do not have a clear diagnosis, but sacrococcygeal teratoma
(SCT) appears to be the most likely candidate. I also still do not
have a medical plan of action, nor anyone to provide treatment, but I
have some clear ideas how to obtain both. Several clinics in the US do
see more than their share of babies suffering from SCT and, if it comes
to it, my insurance might cover fetal surgery. One method is surgery
in which the baby is partly delivered via C-section, the tumor is
surgically removed, and the baby is put back into the uterus to finish
cooking. The baby is later delivered by C-section. This is done only
as a last resort, eg if the teratoma grows so large that it threatens
to cause the baby to suffer heart failure, but this surgery has a
rather good track record. SCTs normally are benign, so if the baby can
survive long enough to have the teratoma removed, one way or another,
the baby's chances of a normal life thereafter are high. I mention
this because I gather, from reading the medical literature etc., that
many women do not receive informed medical care and some become so
frightened for their lives and/or without hope for their baby that they
choose to terminate the pregancy.

There is a Yahoo group that purports to offer support for SCT and other
teratomas, but when I tried to join someone sent me a rude e-mail
demanding to know my name and location. That is not a requirement of
membership, according to the group's web subscription page. This
person also demanded details of my baby's condition. Who knows what
other demands they will make? The e-mail included innuendos about how
if I really needed their support then I would give up my privacy. For
the protection and privacy of the other members of the group,
supposedly. To me, this person's behavior is way beyond creepy. It
reeks of preying on vulnerable pregnant woman.

One website really stands out as excellent:
http://www.sctsurvivor.com/. It is by the father of a beautiful little
boy born with SCT. Elijah's Story has graphic photos. And the Useful
Links has some useful medical links. Most of the support links are to
web front pages for the same disturbing Yahoo group.

[PK]

Pologirl wrote:
> I still do not have a clear diagnosis, but sacrococcygeal teratoma
> (SCT) appears to be the most likely candidate. I also still do not
> have a medical plan of action, nor anyone to provide treatment, but I
> have some clear ideas how to obtain both. Several clinics in the US do
> see more than their share of babies suffering from SCT and, if it comes
> to it, my insurance might cover fetal surgery. One method is surgery
> in which the baby is partly delivered via C-section, the tumor is
> surgically removed, and the baby is put back into the uterus to finish
> cooking. The baby is later delivered by C-section. This is done only
> as a last resort, eg if the teratoma grows so large that it threatens
> to cause the baby to suffer heart failure, but this surgery has a
> rather good track record. SCTs normally are benign, so if the baby can
> survive long enough to have the teratoma removed, one way or another,
> the baby's chances of a normal life thereafter are high. I mention
> this because I gather, from reading the medical literature etc., that
> many women do not receive informed medical care and some become so
> frightened for their lives and/or without hope for their baby that they
> choose to terminate the pregancy.
>

I did not get a chance to respond to your earlier thread, so I'm taking
the opportunity here. I'm sorry you have to go through this. Pregnancy
is stressful enough (or can be) without these added issues.
http://tinyurl.com/ma6qm mentions that the statistics are different for
males and females, but you probably already know that. (the page has
some graphic pics and mentions fetal death and provides no studies).

You seem pretty well read and informed about SCTs so I'm hoping things
go well with the baby and hope there is a very happy outcome to this
pregnancy. hugs and good vibes your way.

> There is a Yahoo group that purports to offer support for SCT and other
> teratomas, but when I tried to join someone sent me a rude e-mail
> demanding to know my name and location. That is not a requirement of
> membership, according to the group's web subscription page. This
> person also demanded details of my baby's condition. Who knows what
> other demands they will make? The e-mail included innuendos about how
> if I really needed their support then I would give up my privacy. For
> the protection and privacy of the other members of the group,
> supposedly. To me, this person's behavior is way beyond creepy. It
> reeks of preying on vulnerable pregnant woman.
>

Well, its definitely rude. And what's to say that the information that
members provide is true anyway ? I hope you find the support you want
soon, and don't have to deal with idiots like these.

<snip>

PK

[Jamie Clark]

Pologirl wrote:
> I still do not have a clear diagnosis, but sacrococcygeal teratoma
> (SCT) appears to be the most likely candidate. I also still do not
> have a medical plan of action, nor anyone to provide treatment, but I
> have some clear ideas how to obtain both. Several clinics in the US
> do see more than their share of babies suffering from SCT and, if it
> comes to it, my insurance might cover fetal surgery. One method is
> surgery in which the baby is partly delivered via C-section, the
> tumor is surgically removed, and the baby is put back into the uterus
> to finish cooking. The baby is later delivered by C-section. This
> is done only as a last resort, eg if the teratoma grows so large that
> it threatens to cause the baby to suffer heart failure, but this
> surgery has a rather good track record. SCTs normally are benign, so
> if the baby can survive long enough to have the teratoma removed, one
> way or another, the baby's chances of a normal life thereafter are
> high. I mention this because I gather, from reading the medical
> literature etc., that many women do not receive informed medical care
> and some become so frightened for their lives and/or without hope for
> their baby that they choose to terminate the pregancy.

It is hard in situations like these, when you find out that your baby is
sick and/or not developing correctly. It's hard for doctors to tell you
absolutely what is wrong, or absolutely what the outcome will be. They have
to tell you the worst case scenario, because if they don't, someone could
later sue them or something. So you have to make decisions based on all
sorts of vague possibilities and some facts, and there is just no easy
answer.

I'm glad that your baby's prognosis is looking better.

>
> There is a Yahoo group that purports to offer support for SCT and
> other teratomas, but when I tried to join someone sent me a rude
> e-mail demanding to know my name and location. That is not a
> requirement of membership, according to the group's web subscription
> page. This person also demanded details of my baby's condition. Who
> knows what other demands they will make? The e-mail included
> innuendos about how if I really needed their support then I would
> give up my privacy. For the protection and privacy of the other
> members of the group, supposedly. To me, this person's behavior is
> way beyond creepy. It reeks of preying on vulnerable pregnant woman.

I'm sorry if the women was rude to you. I joined a support group after we
lost Nathan, and since it was for people who terminated pregnancies due to
various genetic and or physical or chromosomal abnormalities, they were very
careful on who they let into the group. We could post as annonymously on
the site as we wanted, but we had to give the moderator our names and
stories in detail. They were very careful so that anti-abortion people
wouldn't get onto the site and cause trouble to these very fragile and
delicate women who were grieving so deeply. Once in the group, you would
have access to anyone e-mail address, so they were also protecting the
privacy of the current members of the group.

So while I understand the need to do this type of screening, it's too bad
that it was done in a way that felt rude or creepy. You might consider
reconsidering, and joining the group. It's probable that the moderator is
coming across harshly, but that the group is filled with people who could be
very helpful and supportive to you. And if not, you can unsub, no harm, no
foul. Just a thought.
--

Jamie
Earth Angels:
Taylor Marlys, 1/3/03
Addison Grace, 9/30/04

Check out the family! -- www.MyFamily.com, User ID: Clarkguest1,
Password: Guest Become a member for free - go to Add Member to set up
your own User ID and Password

[Anne Rogers]

> to it, my insurance might cover fetal surgery. One method is surgery
> in which the baby is partly delivered via C-section, the tumor is
> surgically removed, and the baby is put back into the uterus to finish
> cooking. The baby is later delivered by C-section.

hmm, interesting, I wonder why that isn't done for twins sometimes, as it
doesn't seem infrequent that twins are delivered prematurely because one if
in trouble, so you wonder if they could do that in that situation

you seem to have done a good deal of research, it should stand you in good
stead as you'll know what questions to ask etc. I do help that you will get
firm diagnosis and plan of action soon

Anne

[alath]

------quote--------
hmm, interesting, I wonder why that isn't done for twins sometimes, as
it
doesn't seem infrequent that twins are delivered prematurely because
one if
in trouble, so you wonder if they could do that in that situation
----------------------

It is done, very rarely. The procedure is called 'septio parva' and
consists of delivering one twin by cesarean section while the other
stays inside. It takes a very unusual mix of risks and benefits for the
procedure to make sense. First of all, the pregnancy has to be at an
early enough gestation to warrant "heroic measures" to prolong
gestation for the second twin - otherwise, if the gestational age is
premature but not critically premature, the balance of risks favors
simply delivering both twins. Also, obviously, the gestational age has
to be advanced enough that the twin being delivered earlier has a good
chance of survival (ie; not previable or peri-viable). So there is a
relatively small window of time that the procedure would ever be
considered. There are a number of other factors, too: the twins have to
be dichorionic and the remaining twin can't have an anterior placenta.
The danger to the twin being delivered early has to be grave enough to
justify endangering the other twin, and it has to be a condition for
which morbidity and mortality would be substantially reduced by putting
the earlier delivered twin in the nursery - enough of an improvement in
outcome to warrant exposing the other twin to risk.

They talk about lightning striking twice in the same place. For septio
parva to make sense, lightning has to strike a hundred times in the
same place. I only personally know of one case. The risk/benefit
calculus for fetal surgery is simpler because the factor of endangering
the other fetus is not present.

There is another rare situation - not as rare than septio parva -
called delayed interval delivery. In this case, when one baby of a
multiple pregnancy delivers early due to preterm labor, and the
subsequent baby(ies) do not deliver spontaneously, it may be considered
to maintain the pregnancy until there is an indication to deliver the
other(s). Again, a lot of factors have to line up just right for this
to make sense.

[Anne Rogers]

> Definitely. New-member screening is not inherently unusual or out of
> order for subject that attract a lot of trolls or fetishists, and where
> intimate family details and children's photos are shared. Some people
> like public, anonymous forums and are happy to run the risks involved,
> others prefer more private, trust-based spaces.
>
> I run one group that requires similar details before joining. In an
> effort to reduce the "creepy" factor, the screening request email is
> sent out with my full name and contact details including instant
> messaging contacts for any prospective members to check me out before
> deciding what to do with their details.

I wonder if it would be possible to contact someone from one of the websites
that have pointed to this group to confirm with them that this is what is
normal. Name and location could literally mean saying Anne, England, not
full name and address. Details of babies condition is also a very general
thing where you would be able to respond, sct suspected at 20 week
ultrasound. You should let the moderator know that you wish that you'd known
that these details would be requested and could they put something on the
front page to that effect and also that the email upset you and could they
look into rewriting it.

Cheers

Anne

[Pologirl]

Anne Rogers wrote:

> > Some people
> > like public, anonymous forums and are happy to run the risks involved,
> > others prefer more private, trust-based spaces.

The problem is that screening new members for any Internet forum, as
such screening is practiced, is simply bogus and the privacy and trust
are illusions. Anne in England may be true, or not; either way, I
don't care. The point is, there is no fundamental difference between
"Anne in England" and "Pologirl". "Anne in England" may appear to be
more real than "Pologirl", but is it? Many Usenet users who appear to
post using their real name in fact are using a pseudonym. With very
few exceptions, we are not anonymous. Anonymity never has been a
feature of Usenet nor e-mail forums, which is precisely why so many
users, especially so many women, use pseudonyms. In the old days, it
was common for men to assume female pseudonyms and build personas to go
with the name, often just for fun but in some cases to live out a very
profound gender identification issue. And it was and remains common
for women to assume male pseudonyms, simply to avoid unwanted attention
from lonely men. And the only thing different about "private" e-mail
support groups is that they are typically moderated by people who have
so little experience on the Internet that they don't understand how
pointless their screening really is.

[Pologirl]

Well, I've had another very extensive ultrasound, with yet another
specialist. At over USD$1,000 each ultrasound, the bills are starting
to add up. And I still don't have a clear diagnosis. The new
specialist is sure that the baby has a neural tube defect (NTD), not a
sacrococcygeal teratoma (SCT). But this specialist has no experience
with SCTs in utero, and could not give any reason to exclude an SCT.

What I need is a fetal MRI and consultation with specialists who do
have significant experence diagnosing and treating both NTDs and SCTs.
The local medical community is not prepared to arrange either of these,
so it is up to me. I am making travel arrangements now. I need to go
a clinic where I don't feel like my case is little more than this
week's pregnancy freak show.

The office manager of my local OB/midwifery practice paid a surprise
visit to my home late one night this week, close to tears, to offer any
personal help she could give. I just about broke down. I could only
say "thank you", give her a hug, and send her home. Isn't it strange,
how so often the pregnant woman in distress is the one who must give
comfort to everyone around her? What incredible power is invested in
pregnancy!

[Jamie Clark]

Pologirl wrote:
> Anne Rogers wrote:
>
>>>
>>> Some people like public, anonymous forums and are happy to run the
>>> risks involved,
>>> others prefer more private, trust-based spaces.
>
> The problem is that screening new members for any Internet forum, as
> such screening is practiced, is simply bogus and the privacy and trust
> are illusions. Anne in England may be true, or not; either way, I
> don't care. The point is, there is no fundamental difference between
> "Anne in England" and "Pologirl". "Anne in England" may appear to be
> more real than "Pologirl", but is it? Many Usenet users who appear to
> post using their real name in fact are using a pseudonym. With very
> few exceptions, we are not anonymous. Anonymity never has been a
> feature of Usenet nor e-mail forums, which is precisely why so many
> users, especially so many women, use pseudonyms. In the old days, it
> was common for men to assume female pseudonyms and build personas to
> go with the name, often just for fun but in some cases to live out a
> very profound gender identification issue. And it was and remains
> common for women to assume male pseudonyms, simply to avoid unwanted
> attention from lonely men. And the only thing different about
> "private" e-mail support groups is that they are typically moderated
> by people who have so little experience on the Internet that they
> don't understand how pointless their screening really is.


But the point is that for a public forum like this, I am aware that it is
open to the public, and I can chose not to reveal things that make me feel
tender or vulnerable. I am aware that there are strangers who have nothing
to do with misc.kids.pregnancy who may be lurking. I don't care if you are
who you say you are. If you say something offensive to me, I can killfile
or block you. Anyone can post here, and no one has to be approved or pass
muster.

But on private groups, especially ones that deal with very sensative issues
such as fetal anomolies or termination, I'd like to know that even if I only
know you as Pologirl or Anne in England, that the person who allowed you
into post onto this group knows that Pologirl is really Terri Jones, who
lives at 1234 Main Street, in Boston, MA, and Anne in England is really Anne
Masters of 555 Longview Lane, London, England. I'll feel comfortable
knowing that someone may have even talked to you on the phone, and that you
are in my group because you have experienced the same type of thing that I
have. You have been vetted, as well as we can vett you.

Of course people can lie about who they are, or their situations, but often,
by asking someone for their story, whether it's a story of a SCT or a
termination for a genetic or physical anomoly, you can often tell if they
are making it up or not. You can tell if they don't have accurate
information, or if it's contradictory, or doesn't ring true. And someone
would have to go to pretty long lengths to learn about a particular issue
scientifically, and then fake the emotional stuff that goes with it, and
it's a lot of work to do that, so most of those wackos would just as rather
post and make trouble in a public forum, where they can make it up as they
go, without immediately having to pass muster.

Yes, privacy and trust are illusions, but nothing is perfect, and I support
and encourage screening in sensative private groups like that. More often
than not, it helps protect the women already in the group. If a women going
through something traumatic feels the need for that kind of support, but
isn't willing to explain honestly who she is and what is going on with her
to a moderator, then I guess she isn't ready to join that particular group.
And that's her choice. You can't expect to get honest support if you aren't
willing to be honest. And not all forums are going to be the right place to
open yourself up, which is why screening is a good thing.
--

Jamie
Earth Angels:
Taylor Marlys, 1/3/03
Addison Grace, 9/30/04

Check out the family! -- www.MyFamily.com, User ID: Clarkguest1,
Password: Guest Become a member for free - go to Add Member to set up
your own User ID and Password

[Jamie Clark]

Pologirl wrote:
> Well, I've had another very extensive ultrasound, with yet another
> specialist. At over USD$1,000 each ultrasound, the bills are starting
> to add up. And I still don't have a clear diagnosis. The new
> specialist is sure that the baby has a neural tube defect (NTD), not a
> sacrococcygeal teratoma (SCT). But this specialist has no experience
> with SCTs in utero, and could not give any reason to exclude an SCT.
>
> What I need is a fetal MRI and consultation with specialists who do
> have significant experence diagnosing and treating both NTDs and SCTs.
> The local medical community is not prepared to arrange either of
> these, so it is up to me. I am making travel arrangements now. I
> need to go a clinic where I don't feel like my case is little more
> than this week's pregnancy freak show.
>
> The office manager of my local OB/midwifery practice paid a surprise
> visit to my home late one night this week, close to tears, to offer
> any personal help she could give. I just about broke down. I could
> only say "thank you", give her a hug, and send her home. Isn't it
> strange, how so often the pregnant woman in distress is the one who
> must give comfort to everyone around her? What incredible power is
> invested in pregnancy!

Hugs Pologirl. If you need to come out to SF, I might be able to put you up
in my guest room. It's 30 miles away from SF proper, and you'd probably
want to be closer to where ever your appointment is, but I have a nice
house, and it's cheap!

We have guests coming in the first week of June, so it wouldn't work then,
but if it's before or after, just let me know. I'd be happy to help out.
You are welcome to e-mail me offline, and I'll give you my phone number if
you want to talk.
--

Jamie
Earth Angels:
Taylor Marlys, 1/3/03
Addison Grace, 9/30/04

Check out the family! -- www.MyFamily.com, User ID: Clarkguest1,
Password: Guest Become a member for free - go to Add Member to set up
your own User ID and Password

[Sidheag McCormack]

Jamie Clark writes:

> But on private groups, especially ones that deal with very sensative
> issues such as fetal anomolies or termination, I'd like to know that
> even if I only know you as Pologirl or Anne in England, that the person
> who allowed you into post onto this group knows that Pologirl is really
> Terri Jones, who lives at 1234 Main Street, in Boston, MA, and Anne in
> England is really Anne Masters of 555 Longview Lane, London, England.

Pologirl's point, and she's quite right, is that that person *doesn't* know
that. I can subscribe to such a group with a made-up name and address.
Anything the moderator can easily check, I can easily forge. If members
feel happier because of the moderator's checks of personal information such
as real name and address, their sense of security is false and dangerous.

> I'll feel comfortable knowing that someone may have even talked to you
> on the phone,

Really? Does any group have vetting that includes talking to potential
members on the phone, even if they live on the other side of the world?
(Even if they do, it still doesn't prove anything - suppose I give my own
unlisted telephone number along with my fake details, and when the
moderator calls me I tell the same false story as I told in email - nothing
gained.)

> Of course people can lie about who they are, or their situations, but
> often, by asking someone for their story, whether it's a story of a SCT
> or a termination for a genetic or physical anomoly, you can often tell
> if they are making it up or not. You can tell if they don't have
> accurate information, or if it's contradictory, or doesn't ring true.
> And someone would have to go to pretty long lengths to learn about a
> particular issue scientifically, and then fake the emotional stuff that
> goes with it, and it's a lot of work to do that, so most of those wackos
> would just as rather post and make trouble in a public forum, where they
> can make it up as they go, without immediately having to pass muster.

*This* is true, and I accept that asking for someone's reason for wanting
to join and story in that sense may be reasonable. However, this doesn't
require personal details such as real name and address. Asking for those
adds nothing - anyone can make those up.

> If a women going through something traumatic feels the need for that
> kind of support, but isn't willing to explain honestly who she is and
> what is going on with her to a moderator, then I guess she isn't ready
> to join that particular group.

It sounds as though you can't imagine someone being prepared to reveal very
intimate aspects of herself, while wanting others - such as concrete
information which might get accidentally or deliberately passed on to
someone who might misuse it - to remain hidden. I can very easily imagine
that, in fact I've done it (openly).

> You can't expect to get honest support if you aren't willing to be
> honest.

To be "honest" it is not necessary to share everything.

Sidheag
DS Colin Oct 27 2003

[Denise~*]

Pologirl wrote:

> There is a Yahoo group that purports to offer support for SCT and other
> teratomas, but when I tried to join someone sent me a rude e-mail
> demanding to know my name and location. That is not a requirement of
> membership, according to the group's web subscription page. This
> person also demanded details of my baby's condition. Who knows what
> other demands they will make? The e-mail included innuendos about how
> if I really needed their support then I would give up my privacy. For
> the protection and privacy of the other members of the group,
> supposedly. To me, this person's behavior is way beyond creepy. It
> reeks of preying on vulnerable pregnant woman.

OK, ignore this person.

> One website really stands out as excellent:
> http://www.sctsurvivor.com/. It is by the father of a beautiful little
> boy born with SCT. Elijah's Story has graphic photos. And the Useful
> Links has some useful medical links. Most of the support links are to
> web front pages for the same disturbing Yahoo group.

This is just bizarre. I thought for a minute you were talking about the
person I knew who had the same problem with her baby (the one I
mentioned in your earlier post) also named Elijah. Check this out.
It's not the same baby, but the same condition & same name. The baby is
just fine & 4 years old now.
http://folks.harbornet.com/raneem/birthstory.html

[Anne Rogers]

"Pologirl" > wrote in message
> Well, I've had another very extensive ultrasound, with yet another
> specialist. At over USD$1,000 each ultrasound, the bills are starting
> to add up. And I still don't have a clear diagnosis. The new
> specialist is sure that the baby has a neural tube defect (NTD), not a
> sacrococcygeal teratoma (SCT). But this specialist has no experience
> with SCTs in utero, and could not give any reason to exclude an SCT.
>
> What I need is a fetal MRI and consultation with specialists who do
> have significant experence diagnosing and treating both NTDs and SCTs.
> The local medical community is not prepared to arrange either of these,
> so it is up to me. I am making travel arrangements now. I need to go
> a clinic where I don't feel like my case is little more than this
> week's pregnancy freak show.

I don't know where you are, so I don't know how things work, but it would
seem to me that if one doctor determines that they cannot care for you then
they really ought to tell you who can and formally transfer you to them, I
would have thought your insurance would need some indication that a
specialist was needed.

Have you asked them what they think you should do? Is it that they don't
think you need the fetal MRI? or that they do think you need it, but that
it's down to you to organise it? If it's the former then have you asked them
what they do plan to do in terms of monitoring things and what happens after
delivery when baby needs surgery? or, if it's that later, then that may well
just be the way things are, even in the UK, where health care is
nationalised, I've come away from a GP appointment this week with a whole
host of letters to write, people to contact etc. and that doesn't seem to be
unusual here, so I can imagine it's even more the case with a private
system.

I'm sorry they are making you feel like a freak, what happened at the end of
my pregnancy was not life treatening to me or the baby, but it was something
that no one had a clue what to do and they definitely treated me in a
strange manner and I'm sure that I got more than my fair share of students
having prod and a poke.

Cheers

Anne

[Joybelle]

"Pologirl" > wrote in message
oups.com...
> Well, I've had another very extensive ultrasound, with yet another
> specialist. At over USD$1,000 each ultrasound, the bills are starting
> to add up. And I still don't have a clear diagnosis. The new
> specialist is sure that the baby has a neural tube defect (NTD), not a
> sacrococcygeal teratoma (SCT). But this specialist has no experience
> with SCTs in utero, and could not give any reason to exclude an SCT.

How frustrating for you!! Are they not seeing any other signs to inicate
NTD, such as enlarged ventricles? Grant had an open NTD, so the amnio did
show signs of spinal fluid in the results, so that helped us there. I'm
curious to know how an SCT and an NTD would look different on an u/s. It
seemed to me the sac was "see-through" and from the pics of the teratomas,
they looked like a large mass.

> What I need is a fetal MRI and consultation with specialists who do
> have significant experence diagnosing and treating both NTDs and SCTs.
> The local medical community is not prepared to arrange either of these,
> so it is up to me. I am making travel arrangements now. I need to go
> a clinic where I don't feel like my case is little more than this
> week's pregnancy freak show.

Argh!!! And why can't they refer you? You definitely need to get with the
specialiasts who have experience. I am so, so sorry they are making you
feel like a pregnancy freak show. :( My husband and I were sent to a
terrific clinic because we're from a very small rural area, and though I
hated, hated the drive, etc, I'm glad we were in specialized hands. I
believe it made a world of difference, and I really hope it isn't too
difficult for you to find someone. It really sucks, though, that you're
having to do all the footwork. It's not like you have enough to deal with,
right?


> The office manager of my local OB/midwifery practice paid a surprise
> visit to my home late one night this week, close to tears, to offer any
> personal help she could give. I just about broke down. I could only
> say "thank you", give her a hug, and send her home. Isn't it strange,
> how so often the pregnant woman in distress is the one who must give
> comfort to everyone around her? What incredible power is invested in
> pregnancy!

(((HUGS))) It's a tough place to be. I found myself giving lots of comfort
at times, and in someways, sometimes, it helped me. Other times, I just
didn't get it.


--
Joy

Rose 1-99
Iris 2-01
Spencer 3-03
Grant 9-05 www.caringbridge.org/visit/grantphilip