386 SPECIAL ARTICLE: MEDICINE IN CANADIAN ARCrIC

MEDICAL OBSERVATIONS ANDPROBLEMS IN THECANADIAN ARCTIC*

OTTO SCHAEFER, M.D.,t Edmonton, Alta.

PART II

NUTRITION AND NUTRITIONAL DEFICIENCIESEsKIMos as well as Northern Indians used to live,as hunters on a diet consisting almost exclusivelyof meat, fsh and fat. The only source of carbo-hydrates of practical importance was large amountsof berries collected by their women and children inthe short sinmers. Indians used to dry enoughberries for an all-year-round supply of this im-portant vitamin and mineral source, while Eskimospreserved only a limited amount by freezing t-hem inthe fall. Eskimos also cherished another source offresh vegetables, the stomach contents of game,especially land mammals. In June and July theyoung leaves of a number of tundra herbs are col-lected and eaten with seal meat and blubber.Similar use is made of certain algee (seaweed). Forthe greater part of the long winter no vegetables orberries are available to Eskimos, yet vitamin or otherdeficiencies are unknown so long as a large part oftheir diet consists of fresh meat and fish, mostlyeaten raw and frozen. Indeed nothing is morevitalizing and more delicious-at least to my tasteafter months of canned meat-than frozen seal andcaribou meat or Arctic char on an exhausting dog-team trip.

It has been claimed that vitamin A deficiencyis to blame for corneal keratitis and opacities inthe North (see section on phlyetenular kerato-conjunctivitis in Part I). Vitamin A is, however, notscarce but rather abundant in the Arctic. All fishand sea mammals as well as their predators containlarge concentrations of it; in fact, recent investi-gations have proven that, for example, the liversof polar bears, tabooed by Eskimos and known aspoisonous to Arctic explorers, do not contain aspecific poison, but only a poisonous concentra-tion of vitamin A. Sled dogs tolerate small pieces

of polar bear liver, but will lose their hair if givenlarger quantities. Squareflipper seal liver seems tocontain even more vitamin A, as dogs show similarbut more severe symptoms after eating small piecesof it. Many seal-eating Eskimos though perfectlyhealthy, have a relatively large liver. This hepato-megaly was first described by Brown'0 and con-firmed by Hildes." Brown ascribed it to their highvitamin A intake, which is believed to facilitatecold acclimatizationVitamin B complex deficieneies were seen to some

degree around trading posts, where large amountsof flour and sugar were consumed, but they havecompletely disappeared since the sale of flour en-

riched with vitamin B became obligatory in the

*This paper expresses the personal views of the author,which are not necessarily shared by the Indian and NortherniHealth Services.tCharles Camsell Indian Hospital, Edmonton.

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N.W.T. One would expect vitamin C deficiencyto be prevalent in the North, since so many Arcticexplorers died of scurvy, but it is actually neverseen in people eating adequate amounts of freshmeat. Slight degrees, manifested as ready bleedingof the gums, occur occasionally after periods ofrelative scarcity of fresh meat. Despite the longdark winters and inadequate ultraviolet radiationat all times, vitamin D deficiencies do not occur inArctic peoples who live predominantly on nativefood and whose children are breast-fed. Severedegrees of scurvy as well as rickets are to be seenin bottle-fed children, who are not given vitaminsupplements.We had an orphan girl in Pangnirtung, who was

reared by the missionary's wife on powdered milk25 years ago. The girl ended up with a rachiticcontracted pelvis. I had eventually to deliver herlarge first son by Cesarean section, the firstEskimo-to my knowledge-born that way withinthe Arctic, under most trying conditions.Vitamin preparations have been distributed in

small amounts to everyone reached by surveys andby nursing stations. It would appear from the afore-said to be more useful, perhaps, to reserve the oftenlimited supply for those people who eat much"white man's food" and to supplement particularlythe vitamin intake of children who are fully orpartly bottle-fed, and those breast-fed ones whosemothers do not eat enough fresh meat.The early mouth-to-mouth feeding of small

amounts of pre-masticated meat and fish, boiledas well as raw, may be another effective factorpreventing scurvy and rickets and providing all im-portant nutritional elements including iron. Thisis started in breast-fed babies usually at four tofive months, to be followed later, when the babyhas enough teeth, with small morsels of fish andmeat. The bulk of nutrition, however, is derivedfrom the mother's milk until the next baby takes,after about three years, its place on the breast.I have seen several well-developed Eskimos, adultsand children, who were pointed out to me as havingbeen exclusively brought up with mouth-to-mouthfeeding from the very first weeks of life, after losingtheir mother post partum or being given away asa twin (an Eskimo woman can keep only one oftwin babies, for there is only room for one in herparka).No mineral deficiencies are known to exist in

Eskimos. I regularly examined the hoemogloblinlevel of pregnant women but finally discontinuedthe practice, as well as the doling out of thecustomary calcium, iron and vitamin pills forpregnant women, in those camps where a gooddeal of fresh meat was consumed. My own findingsin Aklavik and Pangnirtung and reports fromAlaska5 and from the Canadian Eastem Arctic'1show a remarkable uniformity. No cases of anemiawere detected except in rare instances after grosshaemorrhage or in patients with advanced tuber-culosis or cancer. The mean hemoglobin valueswere in each series for male adults, between 15and 16 g. %; female adults, between 14 and 15g. %; children, at or above values regarded asnormal for respective age groups. In contrast,Indians, in particular Indian children, have been

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found to be slightly to moderately anaemic inAlaska,5 and I found the same situation in thelower Mackenzie district. This is probably due toextensive bannock feeding, often supplementedonly by fish.

DIsEAsEs OF DEGENERATION AND CIVILIZATION"Until quite recently the natives of the Americas

were regarded as being free of "degeneration andcivilization" diseases, such as arteriosclerotic cardio-vascular diseases, diabetes mellitus, thyrotoxicosis,peptic ulcer, ulcerative colitis, bronchial asthmaand also neoplastic diseases. Closer examination hasshown this to be only partly true in Eskimos as inother primitive peoples. Changing living conditionsand increasing life expectancy also influence theincidence of such diseases. There remain, however,significant differences. Data collected in the CharlesCamsell Indian Hospital, Edmonton, the MountainSanatorium, Hamilton,12 and different Manitobahospitals,'3 on native patients evacuated from theNorth, and my own experience in the Arctic,indicate that most disorders of neuro-hormonalregulation, psychosomatic diseases, essentialhypertension, presenile arteriosclerosis and someforms of neoplastic diseases have never been ob-served in pure-blooded Eskimos and AthabascanIndians, living in the old native fashion. The rapidlychanging conditions in the Canadian Arctic providea unique opportunity to study the influence ofcivilization upon our health and to differentiatebetween racial-hereditary, dietary and social-psychological factors in the pathogenesis of thesediseases, which are of growing importance for allof us.

(a) Arteriosclerotic and hypertensive cardio-vascular diseases are now the most frequent causesof death in countries with "Western civilization".They are, at present, intensively studied and dis-cussed, with occasional contradictory references topertinent conditions and diets found in Eskimos.Arteriosclerosis and related complications likecoronary atherosclerosis and cerebrovascular acci-dents definitely occur in Eskimos in old age, asclinical experience and postmortem findings haveshown. I remember a man, about 80 years old,with a coronary thrombosis confirmed by autopsy;another one of about 75 with a complete A-Vheart block, and one of 70 with a stroke. My impres-sion after having examined more than 4000 Cana-dian Eskimos, however, is that arteriosclerosis isless common in old Eskimos than in old whites anddoes not appear to exist in Eskimos under 60 yearsof age. Only six pure-blooded adult Eskimos wereincluded in my autopsies performed in the North,and this small number does not allow any con-clusions regarding the actual incidence of arterio-sclerosis. I, therefore, asked the opinion of the twopathologists with probably the greatest autopsyexperience of Eskimos-at least in Canada. Dr. S.Hanson,'4 reviewing approximately 30 autopsies ofWestern Arctic Eskimos performed at the CharlesCamsell Indian Hospital, felt that no markeddifference between old (above 60) Eskimos andold whites existed as regards the state of theirvessels. For the middle and younger age groups,however, he was prepared to state that he hadnever been able to find any presenile pathological

changes in arterial walls. Dr. H. H. Lucke'5evaluated 17 postmortem examinations of EasternArctic Eskimos, performed at Mountain Sanatorium,Hamilton, Ontario. He agrees with Dr. Hansonthat atherosclerosis occurs in Eskimos over 60, butfound it less extensive and severe than in Cauca-sians of the same age group.Keys et al.'6 have collected convincing experi-

mental and statistical evidence that cholesterolkemiaand fat-rich diets parallel the incidence of arterio-sclerosis in different peoples. This has beenquestioned, and health conditions and diets pre-vailing in Eskimos have been cited to disprovesuch a connection.'7 The fats eaten by Eskimosare usually simply described as "animal" fats. Thisis a misleading simplification, at least as far asEskimos are concerned. With the exception ofthe numerically small and insufficiently examinedgroup of Caribou or Inland Eskimos, they livepredominantly on sea mammals and fish. Thesecontain marine fats, which are rich in unsaturatedfatty acids (fish oil, seal oil) and are often shunnedby whites for their repugnant smell. We seem tohave lost the healthy instincts and natural senses ofprimitive peoples, who often crave rancid oxygen-ated (unsaturated) fats. Baffin Island Eskimos havea special treat in summer, namely, Arctic char(a species of salmon with an extraordinarily highat content) sewn raw into sealskins and exposedto the sun for two to three days. By fermentationand oxidation, they thus instinctively enrich theunsaturation of the fatty acids. Similar dietarycustoms are known to exist among the older Chineseand other peoples.The old Eskimo in Pangnirtung, whom I told

about the artificial hardening (saturation) anddeodorization of white whale oil for margarineproduction in Montreal, was perhaps not far fromthe truth, when he mused: "White men can doalmost everything, but they do not seem to havegood sense, for taking the smell away from fattakes all the goodness out of it."

I have no experience with the Caribou Eskimos,but I have examined many Northern AthabascanIndians, who lived on a similar diet of cariboumeat and fish. They showed no markedly higherincidence of arteriosclerosis than Eskimos. Cariboumeat is known for its relatively low fat content, andit is-even in good times-available for only a fewmonths each year, while fish is plentiful most ofthe time and therefore actually constitutes themain nutritional basis for the "caribou" peoples.

Hypertensive cardiovascular diseases are practi-cally absent in Eskimos and Northern Indians. Iremember only two cases with diastolic bloodpressure values above 100 mm. Hg. One of thesecases had renal tuberculosis with blocking of oneureter. The other was suspected of having hadchronic pyelonephritis for years.

Continental workers have always claimed thathigh salt intake would favour the developmentof hypertension. Theoretical and experimentalsupport for this view has been presented by Selye.Dahl"8 has collected overwhelming evidence fromthe literature as well as from his own investigationsfor the role of high salt intake in the developmentof essential hypertension. Eskimos have a naturalaversion against our salty food. They do not,

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however, obtain their salt exclusively from meat,as assumed by Dahl, but achieve at least slightseasoning by adding about one-quarter seawaterto the water in which they boil their meat. Never-theless, the total salt intake is, in my opinion, lessthan Dahl's estimated 3-4 grams a day, as theyalmost never consume the maximal amounts ofmeat allowed by him.

Important as diet may be as a contributingfactor in the pathogenesis of arteriosclerosis andhypertension, it is probably overshadowed byfactors of neuro-hormonal and neuro-vascularregulations, the balance of which seems oftendisturbed by the stress, frustration and constantpressures of our modern way of life. It is certainlywrong to assume that primitive people are notsubjected to stress and pressure. I doubt if thereis, or ever was, a carefree paradise for any peoplein this world. Certainly not for Eskimos, livingunder such hardships and constant threats to theirvery existence. Why and how, then, do stress andpressure exert pathological effects in our modernsociety? I have witnessed many examples of stresssituations, including emotional pressures, in trulyprimitive peoples. These almost invariably led toan irresistible urge for increased and sometimeswild motor activity, which is the natural solutionto stress, as stress evokes in animal physiology anincreased readiness for motor action-to fight orflight. Our modern society has largely lost thehabit or possibility for the motor "work-out" ofstress, while being constantly flogged by sensoryoverstimulation. Another important causative factor,providing much frustration and sustained mentalstress, seems to me to be our loss of the genuinereadiness of primitive peoples to modestly acceptfate and our natural place in the world withoutambitious revolting. But all these factors maymerely influence the manifestation of pathologicalconditions, which are largely determined by heredi-tary patterns, as Page et al.19 have demonstratedfor the low incidence of coronary disease in NavajoIndians.

(b) Psychosomatic and neuro-hormonal dys-regulation diseases.-There are, as yet, no cases onrecord of peptic ulcer occurring in CanadianEskimos. I would like to report a case history whichshows what we may expect in future more fre-quently as a result of increasing problems ofcivilization:

A 19-year-old Eskimo girl, who had spentseveral years in the South, first as a patient and thenin training, was torn between nostalgia for homeand the mounting fear of being unable to cope withlife there and of being ridiculed by her people forhaving lost or never learned the skill to make sealskinboots and skin clothing. We tried to make the transitioneasier for her in a small institution in the EasternArctic. But when she had difficulties in finding herright place among the partly white, partly Eskimostaff, she responded first with a gynecologicalorgan-neurosis, thus transferring her problems backto an area where an irresponsible white man hadfirst disturbed her native balance when she was only14 years old. Later, she developed typical stomachulcer symptoms. The specific choice of this organ mayhave been provoked by the general tension and feeling

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of insecurity arising from the girl's and the manage-ment's indecision as to whether she should take herplace at the dining table for white or Eskimo personnel.My psychotherapeutic efforts were only partly success-ful, but she lost ail symptoms when some of ourEskimo girls befriended her and taught her how tocut and sew her own parka and sealskin boots.

True bronchial asthma has never been seen inpureblooded Eskimos and Northern Indians. Thisis remarkable, as recurrent bronchitis and allergicreactions, both believed to be contributing factorsto the pathogenesis of asthma, are quite oftenfound in Eskimos. Although they generally havevery deep, "barrel"-shaped, mighty thoraces, trueemphysema is not very common despite the fre-quent irritation of the bronchi by the extreme cold.Urticaria and angioneurotic cedema were seen onseveral occasions, and allergic reactions to strepto-mycin were not uncommon. But the central psycho-somatic factor and pathogenetic pathway producingtypical asthma attacks just does not seem to existin our Northern natives-yet.To date no cases of Graves's disease or of clini-

cally evident hyperthiyroidism have been describedin Eskimos.

I learned recently of a patient with a colloid goitre,who comes originally from Inland Eskimo stock south-east of Coppermine. He had a large thoracoplastyseveral years ago and was now readmitted for question-able reactivation of his pulmonary tuberculosis. Hedenied any thyroid symptoms and claimed to havehad the goitre since his youth. But his thyroid functionwas investigated: B.M.R. plus 20; P.B.I. within, 1131uptake and conversion rates above, normal range. Hewas given a therapeutic dose of radioactive iodine.The pulse rate remained unchanged (pulmonarycauses? he was dyspnoeic on exertion). I131 figures canbe elevated in iodine-deficient goitres during thehyperplastic phase. I feel that this Eskimo is notsuitable to be described as a first case of Graves'sdisease in Eskimos. More metabolic studies of Eskimosare necessary before we can classify certain laboratoryfindings as "abnormal" in Eskimos. If the results ofQueen's University Arctic Expeditions 1949 and 1950can be confirmed and Brown'slo theory is right, thata relative hyperthyroidism is part of the Eskimo'scold adaptation mechanism, then, indeed one shouldbe most careful before attempting "normalization".

Contradictory findings on basal metabolism analyseshave, however, been reported. Rabinowitch and Smithfound an average B.M.R. elevation- of plus 26% in theEastern Arctic. But they examined subjects during thehectic days of ship-time, when most Eskimos work orfeast day and night, with great excitement and verylittle sleep. Levine, working in Alaska under moresuitable conditions, found no significant deviations fromnormal values. Brown et al.10 found in SouthamptonIsland Eskimos an average elevation of plus 27% duringthe second week of July and of plus 21% at the endof August. Brown concludes that the small but signifi-cant drop during the summer weeks may represent anadaptation to warmer conditions and may suggestmuch higher metabolic rates prevailing in winter aspart of cold adaptation.

Having lived with Eskimos through all seasons forfour years, I find it difficult to follow these conclusions

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for the following reasons. Early July is a time of muchfeasting and little sleep. Sea mammals, fish, fowl andfowl eggs are plentifuil theniand eaten in great quanti-ties. We were impressed year after year by theseasonial restlessniess overcominig natives in late springand early summer, when hu-nting or feasting go onthrough most nights. They theni tend to lose weight.In contrast, they usually grow rounid and fat, sleeping12 or more houirs daily, in the often lean early winitermonths. In Jtuly, Eskimos are often found sweatingprofusely and actually sufferinig from the "heat". InAugust, nights are less bright anid "hot", allowing morenight rest. Pulse rate and blood pressure amplitude,which are good cliniical indicators of thyroid activity,were found perfectly nlorimnal in Eskimos. I had nomeans to measture B.M.R., P.B.I., 1P31 uptake andconversion. Stuch tests should be carried out dturingall seasons in suiitable places such as Cambridge Bayor Frobisher Bay.

The perfect functional balance of the entirehormnonal system is probably best demonstratedby the striking reliability of the interwoven func-tions of lactation stimnulation acnd ovulation suppres-sion.

Birth control is unknown to Eskimos, but theirchildren are born evenly spaced, mostly threeyears apart. This amazingly uniform patternbecomes less regular in families employed by whitesand in those living around the trading posts, wherethe intervals often shrink to two years and less.The intervals have become particularly short inAklavik, Tuktoyaktuk and Frobisher Bay recently,where the population lives largely on "white man'sfood". A similar development was noticed in Alaska.American authors referred to the "influence ofhigher carbohydrate intake on the fertility rate ofEskimos", postulating scarcity of certain fertilityfactors in their exclusively meat and fat diet. I wasmore impressed by the close parallelism of theincreasing bottle and Pablum feeding in infantsand shortening of the intervals between pregnan-cies, which was not discussed in the Alaskan report.Milk powder and Pablum are available in the firstplace to those who can also buy flour and sugar.Vital statistics show a great rise in birth rates inrecent years, even in those Indian and Eskimocommunities where flour and sugar have beenused widely for 50 or more years. The changingfactor was apparently not introduction of carbo-hydrates, but shortening or abolishing of lactation,which is a more recent development. My view issupported by observations in South African natives,who showed a similarly changing fertility patternwith decreasing length of breast feeding.

I made a family list of all Eskimo camps in theCumberland Souind and Davis Strait (E6-) districtin Baffin Island, and this demonstrates the increas-ing birth rate and the decreasing regularity ofbirth intervals as one approaches Pangnirtung, thedistrict's trading post. A typical family list froma remote camp is the following: KOAGA, husband,b. 1919; MARY, wife, b. 1923; children born 1939,1942, 1946, 1949, 1952, 1956. Many families reflectedthe high infantile mortality rate by one or moreintervals of 4-6 years. The few siblings less thantwo years apart all belonged to families employed

by whites. I was first inclined to regard suchreliable suppression of ovulation during the first2-21/2 years of lactation as a racial characteristic.It certainly does not seem to be very dependablein white women. But no remarkable difference inthe gestation intervals of pure-blooded Eskimowomen and those of mixed blood was evident aslong as they lived in a truly native manner. Theimportant factor appeared to be that the childrenbe really fully breast-fed with only some pre-chewvedmeat added later in infancy.

Diabetes mellitus is another endocrine andmetabolic disorder which does not appear to existin pure-blooded Eskimos, living on their nativediet. I have carefully searched for cases, but couldnot find one during four years of medical activityin the Arctic. But even under hospital conditionswith the sudden change to a high carbohydrate diet,no diabetes has been found so far in Eastern ArcticEskimos. 1 Three Western Arctic Eskimos, patientsin the Charles Camsell Hospital, have been dis-cussed as possible cases. None of them presenteda clinical picture of frank diabetes mellitus. Thefindings of occasional glycosuria and slightlyelevated or borderline glucose tolerance tests wereinconsistent. Most fasting blood sugars also werenormal, some subnormal. One of these "diabetes"cases had terminal carcinoma of the vagina withcachexia, another a severe long-standing osteo-myelitis, at the time of the slightly abnormal labora-tory results. There remains only a 50-60 year-oldEskimo woman from Coppermine with a trulypathological glucose tolerance test under admissibleconditions. I do not know, however, whether wecan classify her as a true diabetic. She managedto maintain perfectly normal blood sugar andurine conditions as long as sudden peaks of carbo-hydrate intake were avoided. Pathological resultsof glucose tolerance tests are known to be foundin normal whites after weeks of carbohydratestarvation. This must be considered when examin-ing Eskimos. Our old Eskimo lady had not yetlearned to react to an unphysiological carbo-hydrate peak within our normal standards, evenafter several months of eating our mixed diet, but isthat really pathological after a lifetime on meatand fat? Old age brings shrinking elasticity notonly of forms but also of physiological functionsand adaptation potentials. I am indeed surprisedthat we do not find many more old Eskimos withmild diabetes as a result of the great dietarychanges during the last years in the CanadianArctic. Careful studies may reveal during thecoming years whether racial or dietary factors areresponsible for the conspicuous absence or rarityof diabetes mellitus in Eskimos.A survey of public health conditions in Alaska22

discovered 44 new diabetes cases in 15,000 Indiansbut none in 16,000 Eskimos. The two races werethought to have been screened to a comparableextent during the five-year survey period, whichlends significance to the finding of such a strikinglydifferent incidence. Scott and Griffith20 examinedthe blood sugars of 869 Eskimos serving as NationalGuardsmen, as well as 173 men and 185 womenolder than 35 in the six largest Eskimo settlementsin Alaska. They found only three persons withelevated blood sugars. Two of these were half-

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whites and the third was a 58-year-old woman witha slightly prolonged tolerance curve. The diagnosis"diabetes mellitus" has so far been made in fiveAlaskan Eskimos in hospitals. Only three of thesecould be confirmed, all from the vicinity of Nome,where many Eskimos of mixed origin are living.Gout is unknown in Eskimos and Northern

Indians despite their purine-rich diet. No otherdiseases due to inborn metabolic errors have beenfound.

(c) Neoplastic diseases do occur, but they areless common and of different type-prevalence thanin whites. For example, cancer of the breast, oneof the commonest malignancies in white females,has not yet been proven in pure-blooded Eskimos.There were single cases reported from Labrador(half whites) and from Ungava Bay, but neithercase was confirmed by a pathological report.17 Wehave learned in the Charles Camsell Indian Hospi-tal how careful one should be with the diagnosisof breast cancer in Eskimos, as in two cases thisdiagnosis was made by competent surgeons, andtuberculosis of the breast was proven bv histologicalexamination. There appears to be a conspicuousincrease of breast cancer in Indians exposed forseveral decades to "white man's" habits, i.e. un-physiologically short lactation periods or even"drying up" of the breasts with cestrogens. Similarobservations have been made in Bantus in SouthAfrica, and in women living in "civilized" culturesthe incidence of mammary cancer has increasedas breast feeding has declined.23 The conspicuousabsence of this type of malignancy, which seemsespecially influenced by endocrine factors (andlikely also by the unnatural disuse of stimulatedglands), reflects again the ideal hormonal balancein Eskimos and other primitive peoples.Lung carcinoma: If smoking alone causes lung

cancer, we should expect to find many cases inEskimos and Indians, who almost all smoke quiteheavily, mostly cigarettes in recent decades. Nobronchogenic cancer has been found, however, inNorthern natives by our x-ray survey teams, nowregularly combing the Mackenzie district and theEastern and Western Arctic, or in the Charles Cam-sell Hospital and Mountain Sanatorium.'2 Whilelung cancer has been found in Southern Indians, itis not known to exist in Northern Indians who hadnot yet any occasion to inhale much air pollutedby car exhausts and industrial fumes. I feel there-fore inclined to suspect the latter factors as poten-tial carcinogens. Two cases of lung cancer havebeen reported from Chesterfield Inlet. Fifteen caseswith malignant tumours have been reported since1950 from this relatively small group in the SouthernCentral Arctic, comprising only about 10% ofCanada's Eskimos, yet accounting for more malig-nancies than the remaining 90% so far! The 15cases were classified as: 5 parotid, 2 cesophagus, 2lung, 2 rodent ulcers, 1 bladder, 1 gallbladder, 1sigmoid, 1 intestinal (non-specified) carcinoma.13Of a total of 24 Eskimos with neoplastic diseasesseen from 1950 till the beginning of 1958, 12 cameoriginally from the Eskimo Point-Padlei district.This barren area is populated by fewer than 500Eskimos, predominantly inland or Caribou Eskimos.The incidence of tumours in this small isolated groupis 20 times that in the rest of the Canadian Eskimos,

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and this incidence is highly significant even if thenumbers involved are small. I am inclined to lookto local factors for an explanation. The northernlights (aurora borealis) with known electromag-netic and unknown radioactive (?) or biological(?) effects in our ionosphere and atmosphere aremost frequent and of greatest intensity just north ofthe 600 parallel and roughly around the line Win-nipeg-Prince of Wales Island (area of the northmagnetic pole). This is the area populated by theCaribou Eskimos. With great hesitation and onlyin the hope of stirring up an investigation of greattheoretical and even possible practical interest (be-cause of the mining and defence developments inthat area) do I express this fantastic-soundingpossibility. Inbreeding in such small, isolated groupsmay account for potentiation of pathological genes.A relative preponderance of tumours due to em-bryological development errors seems to exist inEskimos. We saw one mixed tumour and one car-cinoma of the parotid in the Charles Camsell Hos-pital and one dermoid cyst of the ovary in anEskimo who also had a cancer of the vagina. Oneproven case of hypernephroma was also seen. (Seealso below-relative frequency of malformations.)Stomach cancer is extremely rare, while, in

contrast, cesophageal carcinoma is commoner. Oneold Mackenzie-delta Eskimo was suspected clini-cally of having an cesophageal tumour, but onoperation this was found to be histologically acarcinoma of the cardia invading the cesophagus.From Eskimo Point (west coast of Hudson Bay),two cesophageal cancers were reported.

Cervical carcinoma is probably the only majorform of cancer which has no definitely lower inci-dence in Eskimos and Indians. I have seen threecases in the North; two of these were in Eskimos.Malignant diseases other than carcinoma include:one case of malignant chorionepithelioma in a youngEskimo woman from the Hudson Strait,12 and onecase of malignant lymphogranuloma in an Eskimofrom Aklavik (of Alaskan origin).

MALFORMATIONSMalformations, such as harelip, cleft palate or

coloboma, occur, in my opinion, in the Easternand Central Arctic more frequently than wouldbe expected in the same numbers of whites. In thePangnirtung (E 6-) district with a population of650-700 Eskimos, I counted three living Eskimoswith cleft palate and was told of about two morebabies who had died with extensive cleft palateand/or harelip within the last 20 years. The trueincidence may be even higher. Most Eskimobabies with such deformities naturally do notsurvive, and the parents tend to withhold in-formation about them for fear of ridicule. I sawone more case in the Central Arctic and one inSouth Baffin Island, and heard about several othercases there.

I have collected family histories of all cases withmalformations and with abnormalities of the thirdstage of labour which I saw or had definiteknowledge of in the E 6-district. My Eskimoguide instigated this study by bringing me awoman for delivery with the remark that all thewomen of the family had trouble in expelling the

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Fig. 3.-F.W., a half-Eskimo suffering from polyarthritis,showing his scars from the "water-letting" jack-knife treat-ment, performed by his Eskimo uncle, who was an old"Angakok". i.e. medicine-man.

placenta. Indeed, her mother and two maternalaunts had died of post-partum hiemorrhage andthe patient herself had almost bled to death afteran incomplete abortion. Her sister had also hada retained placenta after the delivery of a boywith urogenital abnormalities. Her youngest sisterand one cousin had cleft palates. Two childrenwith cleft palates had died as babies in this familygroup.

I removed her placenta, which was partially aplacenta accreta, with difficulty.

Retention of the placenta occurs surprisinglyoften in Eskimos, and many old Eskimo womenhave experience with manual removal.

I remember old Asheva telling me the story of thedelivery of her adopted son Isayasy, who had a cleftpalate and whose mother had a retained placenta.Asheva demonstrated with her fingers how she hadto shear the placenta from the uterine wall. I couldnot help but stare at her long, black fingemails andexclaim: "You went into the uterus like that?!" Sheglanced up surprised, noticed what I was staring at,and smiled: "Eskimo not that dumb, knows howsoft womb inside; chews nails off, before going in!"

Hildes counted four persons with iris colobomatain 1200 Eastern Arctic Eskimos in 1957.11 Two ofthese occurred in one family. I saw one additionalcase in Coppermine. No coloboma of the retinawas seen. We saw in 1955 two cases of hereditaryoptic atrophy in an Eskimo camp on the HudsonStrait. Myopia is rare, astigmatism more frequent.The latter may sometimes be caused by cornealscarring due to phlyctenular disease. Glaucoma is

unknown in pure-blooded Indians.24 I observed,however, two cases of primary glaucoma inEskimos.

Epilepsy is often seen in Eskimos. The commonfamilial incidence suggests that most cases areidiopathic, but in a few cases cerebral tuberculo-mata have been demonstrated in the CharlesCamsell Hospital. Not all reported "fits" are dueto epilepsy. Hysterical seizures are not infrequentlyexhibited by Eskimos, as by other primitivepeoples, as a primitive form of psychomotor re-action. In Eskimo children our first considerationis tuberculous meningitis.

Congenital dislocation of the hip has not yetbeen observed in Eskimos, though relatively fre-quent in Cree Indians around Island Lake,Manitoba,25 and in one band of Alaskan Indians,5in Navaho and several other Indian tribes.Gray25 is inclined to explain the markedly dif-ferent incidence of this abnormality in Americannatives at least partly by the fact that youngEskimos spend most of their life up to three yearson the back of their mothers with the legs flexed,abducted and outwardly rotated. On the otherhand, he found the papoose board, which immo-bilizes the legs in the position most apt to mani-fest a tendency for dislocation, still used by theManitoba Indians with the highest incidence ofcongenital disclocation of the hip.Congenital heart disease was seen occasionally.

Hildes" described two cases in 1200 Eskimosexamined. I have seen another Eskimo from theCentral Arctic, and one "blue baby" with con-genital heart disease died near Pangnirtung.Rheumatic heart disease does occur, although

probably less frequently than in whites, due tolesser exposure to hiemolytic streptococci. In morethan 4000 Eskimos I saw two girls with mitralstenosis, one man with a cerebral embolus secon-dary to rheumatic valvular disease, and one manwith severe heart failure probably due to rheu-matic heart disease. One young Eskimo wasrecently seen in Camsell Hospital with aorticinsufficiency. Only once did I see a full-blown picture of acute rheumatic fever, and thatwas in a part-white boy. His uncle, an old"Angakok" (medicine man), had "drained the water"from the swollen knee- and ankle-joints with thehunting knife (see Fig. 3). Thirty years earlier,the Angakok's surgical skill was better placed,when he relieved an acute bladder retention ofour boy's grandfather, an old white trapper, bycystotomy. Rheumatoid arthritis is uncommon inpure Eskimos, but is often seen in white trappersand somewhat less frequently in half-breeds inthe Arctic.

Malocclusion due to prognathy of the lower jawis common in Western Arctic Eskimos, especiallythose of part-Alaskan origin (see Fig. 4). Anthro-pological factors, namely mixture of mongoloid-brachycephalic with primordial extremely dolicho-cephalic race elements, may be responsible for thisas well as for the primordial, rectangular con-figuration of the dentures, seen not infrequently inEastern Arctic Eskimos, as opposed to our rounddental arches. Dental caries occurs in relation tothe consumption of flour and sugar and is there-

3092 SPECIAL ARTICLE: MEDICINE IN CANADIAN ARCTIC

-~~~~ -:

(a) (b)Fig. 4.- Dental abnormalities due to anthropological

causes: (a) old Susie Tum-ia, Aklavik, of part-Alaskan origin,showing imialocclusion due to short (miiongoloid) nmaxilla andlar-ge (primiiordial) nmandibula.Teeth out of line are often seen in Alaskan and Mackenzie-

delta Eskimos, being seen less frequently as one moves east-wards. In the Eastern Arctic, jaws are nmighty and are longas -vell as large. In the East, the nmaxilla usually fits themandibula wxell, and prominent canine teeth (and strongchew%ving muscles?) not infrequently cause a deviation in thedentur-s fr-om-l the ar ch fornm to a rectangular alignment asseen in (b), a younig Eskimo from the Eastern Central Arctic.

fore very common, e.g. around Aklavik. Eskimoteeth are often worn down by chewing raw meat,fish and whaleskin. This process is accelerated inwomen by the daily chore of chewing skin clothingand sealskin boots to make them pliable againafter drying. These teeth, deprived of their pro-tective enamel, nevertheless keep healthy into oldage as long as no carbohydrates and their fer-mented acids touch them (see Fig. 5).

TRAUMATIC DISEASES DUE TOCLIMATIC AND LOCAL CONDITIONSEskimos, Indians and whites alike suffer in the

Arctic and Subarctic regions from frequent andoften severe nosebleeding. This is probably causedby the extremely cold and absolutely dry air.The nasal mucosa develops many telangiectases,which tear easily with the damaged epithelium.I found the application of a covering layer ofVaseline or blubber a simple and effective pro-phylaxis.Drowning of children and, rarely, also of hunters

happens every summer in the labyrinth of channelsand lakes in the Mackenzie delta. The loss ofhunters is greater in the EasternArctic, where most are lost inwinter and spring, whilst hunt-ing on the ice-flow edge, whichmay break off in sudden storms. -Marooned on drifting floes, Eski-mos have endured days and insome cases even weeks of starva-tion and exposure uintil their ice ..floe drifted ashore-or perishedin the open sea. The greater lossof men used to balance thegreater sacrifices of young girlsin starvation times. Nowadays,higher tuberculosis morbidity andmortality of women (lessened re-sistance in gestation and lacta-tion periods and poorer nutri-tion) seem to have establisheda new balance of sexes.

Canad. M. A. J.Sept. 1, 1959, vol. 81

Severe frostbite and death due to freezing areuncommon in the Western Arctic. Sudden blizzardsthere have probably trapped more whites thannatives in the last decades. Frost damage is ofgreater importance in the moist-cold Eastern Arctic,where with the advent of the rifle the dangeroushunting on the floe-edge has superseded thetedious hunting on breathing holes.

The incredible physical endurance, patient fortitudeand resourcefulness of Arctic hunters is probably bestshown by relating the story of my first patient withfrozen feet, who was brought to the PangnirtungHospital on December 2, 1956. A sudden storm hadbroken large floes off the young shore-ice near a campon the west coast of Cumberland Sound. Ahme,about 18, and Aoyalo, about 40, were driven acrossthe northern part of the Sound. The next day, theytried to make their way over thin and broken floesto the eastern shore. Aoyalo went ahead, feeling hisway with the harpoon rod; Ahme followed with thedogsled. The ice broke under the sled and Ahmetumbled into the water. He eventually regained firmice after breaking several times through thin layers.But as there was not enough snow on the new iceon which to roll himself and his clothes dry, theyran several miles to laand, where Aoyalo fin,ally foundsuitable snow for an igloo. Aoyalo had returned onlya few months previously after having been confinedfor seven years in Dartmouth mental hospital andit took him much too long to build the igloo. Ahmekept running in circles until he fell exhausted onthe snow. His water-filled boots aand already painlessfeet soon froze rock-hard in the 200 F. below zero bliz-zard. Aoyalo eventually pulled him into the completedigloo and began to thaw his frozen boots over theprimus stove. He then thawed the frozen feet on hisown body beneath his skin clothing. They had nodry clothes to chaange into, no sleeping bags andno food reserves, as they had been hunting justbefore their home camp. After an hour the last ofthe kerosene was burnt and for the niext two nightsand a day Aoyalo tried to drive Ahme and himselfaround, stamping the snowz in order to avoid freezingto death. There was nothing but snow to eat. Wbhenthe blizzard subsided the second morning, Aoyalolashed the inow completelv lethargic vouing fellowon his sled and hurried as fast as possible over rocky

(b)Fig. 5. - Samonie. Eskimo womian

from Pangnirtung, N.W.T. (a) CheNwing-soft, pliable sealskin boots. (b) Close-ul)of her teeth, showving evenly wvorn-down (in lower jaw- down to guns),but perfectly healthy teeth.

Canad. M. A. J SPECIAL ARTICLE: MEDICINE IN CANADIAN ARCTIC 393Sept. 1, 1959, vol. 81

hills and rough sea-ice to the next Eskimo camp.From there, new teams rushed them to Pangnirtung,but, by then, the greater part of the right foot anda small portion of the left were gangrenous.More fortunate was a 17-year-old Eskimo. He had

broken through the new ice on the Pangnirtungfjordjust five or six miles from the post. Shaking off hismitts he had worked himself with his fingers up on tothe smooth new ice and then run for his life.

But despite such fortitude, endurance and in-genuity, many hunters never return to tell theirstories. There are no headlines and no heroicspeeches. Elata summed up the fates of manyhusbands and sons of the Baffinland Eskimos,when I asked her about her first husband:"AUDLAUKPOK; TIKELAUNGILAK;-AYUNA-MAT." (He went out hunting; he did not comeback; - there is nothing one can do about it.)

SUMMARYOur northland and its native population are rapidly

growing in importance to Canada and the WestemWorld. Lasting progress can only be based on ahealthy population. As in other primitive peoples, theimpact of civilization was at first rather destructivefor our northern natives, destroying or changing theirbasis of existence, their social structure and culturaltraditions, and bringing them new diseases, for whichthey had not developed any resistance in theirisolation.

Tuberculosis, favoured by climatic and housingconditions, became the main plague, killing wholefamilies and entire tribes. The prevailing forms oftuberculosis, other infectious diseases and immunityproblems are discussed. Immense difficulties are metin bringing help to the scattered population in thevast, trackless country. Great progress, however, hasbeen made by the Indian and Northern HealthServices, particularly in the fight against tuberculosis.Of special interest to our modern society, which

suffers increasingly from diseases of civilization, is theabsence or significantly different incidence of these dis-eases among primitive peoples. The Eskimos, who arenow subjected to abrupt changes in their nutrition,occupation and their entire way of life, present uswith unique opportunities to study and differentiatethe effects of these environmental factors from here-ditary characteristics. An attempt was, therefore, madeto survey pertinent data, collected from the mainhospitals treating Eskimos, and during four years offield service in the Canadian Arctic.

I feel indebted to Dr. J. A. Hildes, Associate Professorof Physiology and Director of the Arctic Medical ResearchUnit, University of Manitoba, for his valuable advice, toMax Clark, Charles Camsell Hospital, for his help insearching the medical records for relevant cases, and toDrs. Robert Pledger and Thomas Eid for correcting myEnglish.

REFERENCES

1. LEER, R. H.: Eye Digest, 1: 25, Jan. 1957.2. MILLER, M. J.: Ca4utd. M. A. J., 68: 423, 1953.3. MELTZER, H. et al.: Ibid., 75: 121, 1956.4. DAVIS, T. R. A.: Am. J. Med., 23: 99, 1957.5. COLYAR, A. B.: Arctic Health Research Centre,

Anchorage, Alaska: personal communication to Dr.W. J. Wood, Winnipeg, Man.

6. DAVIES, L. E. C.: Indian & Northern H.S., personalcommunication.

7. KUITUNEN-EKBAUM, E.: Canad. J. Pub. Health, 41: 34,1950 (abstract).

8. KUITUNEN, E.: Ibid., 45: 30, 1954 (abstract).9. HILDES, J. A., WILT, J. C. AND STANFIELD, F. J.: Ibid.,

49: 230, 1958.10. BROWN, G. M.: Metabolic studies of the Eskimo, In: Cold

injury, Transactions of the Third Conference, Feb.22-25, 1954, Fort Churchill, Manitoba, edited by M. I.Ferrer, Josiah Macy, Jr. Foundation, New York, 1955,P. 52.

11. HILDES, J. A.: Canad. Serv. M. J., 14: 24, 1958.12. PEART, P. E.: Personal communication.13. WOOD, W. J.: Personal communication.14. HAN'SON, S.: Personal communication.15. LUCKE, H. H.: Personal communication.16. KEYS, A. et. al.: Ann. Int. Med., 48: 83, 1958.17. LAWSON, R. N.: Personal communication.18. DAHL, L. K.: New England J. Med., 258: 1152, 1958.19. PAGE, I. H., LEWIs, L. A. AND GILBERT, J.: Circulation,

13: 675, 1956.20. ScoTT, E. M. AND GRIFFITH, I. V.: Metabolism, 6: 320,

1957.21. KING, A. G.: J. M. A. Georgia, 47: 342, 1958.22. CAss, E. E.: Personal communication.23. GRAY, G. C.: Personal communication.

CANADIAN JOURNAL OF SURGERY

The July issue of the Canadian Journal of Surgery con-tains a varied series of original articles in addition to asection on the history of surgery in Canada, case reportsand book reviews. The contents list is as follows:

History of Canadian Surgery.-Une operation chirurgicale'a l'Hotel-Dieu de Qu6bec en 1700 (E. Gaumond); Chirur-giens canadiens d'autrefois (C.-M. Boissonnault).

Original Articles.-The Recognition and Management ofTraumatic Ruptures of the Tracheo-Bronchial Tree (E.D. Gagnon). The Surgical Treatment of Achalasia of theCEsophagus (C. E. B. Abbott, W. C. MacKenzie and C.A. Ross). Cysts and Cystic Tumours of the Anterior Media-stinum (M. Beaulieu, W. Caron and B. Paradis). The Re-covery of Tumour Cells from Venous Blood Draining Cere-bral Gliomas: A Preliminary Report (T. P. Morley).Effects of Gradual Complete Occlusion of the HepaticVeins (P. B. R. Allen and S. Kling). An ExperimentalStudy of Tendon Suturing Techniques (R. J. Cowan andA. D. Courtemanche). An Evaluation of Aseptic andAntiseptic Techniques as Practised in a Modern Hospital.II: Surgical Wards and Dressing Stations (G. E. Myers,M. W. Nimeek and W. C. MacKenzie). Recent Experiencewith Absoess of the Prostate (P. G. Klotz). Acute andChronic Breast Abscess (T. S. Wilson). Replacement of aSegment of the Common Bile Duct by an Ivalon Prosthesisin Dogs (C. C. Krause and A. B. McCarten). Gastric Polyps(G. R. Davies and B. A. Jackson). Small Bowel Obstruc-tion: A Review of Operative Cases from the Royal Alex-andra Hospital, Edmonton, 1953-1957 (H. L. Richardand J. Hnatuik). New Instruments for Sympathectomies(A. C. Abbott).Case Reports.-Intra-Atrial Myxomia: Review of Litera-

ture and Report of a Right Atrial Myxoma Diagnosed Pre-operatively and Successfully Treated (R. K. Padhi andR. B. Lynn). Dupuytren's Contracture: Heredity as anEtiological Factor (S. D. Gordon). Retroperitoneal Lip-oma Causing Renal Displacement (R. G. Winram andJ. N. Ward-McQuaid).

This issue of the Canadian Journal of Surgery also in-cludes an index to all four issues of Volume 2.

B;ack copies of the Journal may be obtained from: Can-adian Journal of Surgery, 150 St. George Street, Toronto5, Ontario.