Why Dental Caries with Modern Civilizations? IV. Field Studies in Primitive and in Modern Outer Hebrides, Scotland

This is the fourth in a series of field studies by Dr. Weston A. Price that were published in The Dental Digest during the 1930s. This article appeared in the June 1933 issue (Volume 39, Number 6).

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The previous reports of the results of field studies in which a search was made to find communities with high immunity to dental caries have included only inland districts of Switzerland. All the districts reported as providing a high immunity were at altitudes of several thousand feet. It has been shown, however, that altitude was not the controlling factor since St. Moritz with its low immunity to tooth decay is at a high altitude similar to the districts in the Loetschental valley; Grachen and Visperterminen of the Visp valley; and Ayer of the Anniveries valley all in the Canton of Wallis (Valais). Herisau in the lower plains district of Switzerland, near Lake Constance, at an altitude of about a thousand feet, was also shown to have a low immunity to tooth decay. The characteristics that have been found to be controlling factors have been (1) physical isolation such as to compel the residents of favorable districts to depend practically entirely on locally produced foods, primarily because of the difficulty of shipping modern foods into those communities, and further, (2) that as rapidly as transportation facilities developed sufficiently to permit the ingress of modern foods, immunity was lost. The basic foods of the groups found to have a high immunity in Switzerland were rye and dairy products with little fruit and a limited amount of green vegetables which were restricted largely to the summer time. Meat was eaten about once a week. We are immediately confronted with the question as to whether the factors that provide immunity are restricted to rye and dairy products or whether other combinations of foods may be equally effective. This has indicated the need for similar studies to be made of districts at ocean level where entirely different basic foods are available.

Accordingly a study was made of islands that were sufficiently isolated to compel the inhabitants to depend on their primitive natural foods. Among such islands are the Outer Hebrides lying off the northwest coast of Scotland and extending to a latitude almost as far north as the southern part of Greenland. The studies to be recorded herewith are, therefore, chiefly of some districts in the Outer Hebrides.

The Isle of Lewis has a population of about 20,000 people made up almost entirely of fisher-folk and crofters or sheep raisers. The island has so little lime in its soils that it is said that there is not a tree in the entire island except a few that have been planted. The surface of the island is largely covered with peat varying in thickness from a few inches to 20 feet. This peat, which furnishes the fuel, still contains the rootlets of the plant life that grew many centuries ago. There is so little bacterial growth that vegetable products undergo slow decay. The pasturage of the island is so poor that few cattle are to be found, largely because they do not properly mature and reproduce. In a few districts some highland cattle with long shaggy hair and horns that are wide apart are grown, but these are for the most part imported. The principal herd of cattle on the island consists of a few dozen head in the government experimental farm. The basic foods of the islanders are fish and oat products and a little barley. Oats is the one cereal that develops fairly readily and it provides the porridge and oat cakes which in many homes are eaten regularly in some form with each meal. The fishing around the Outer Hebrides is especially favorable and small sea foods including lobsters, crabs, oysters, and clams are abundant. An important and highly relished article of diet has been baked cod’s head stuffed with chopped cod’s liver and oat meal.

The principal port of the Isle of Lewis is Stornoway with a fixed population of about 4000 and a floating population of seamen over week-ends of an equal or greater number. The Sunday we were there, there were said to be 450 large fishing boats in the port for the week-end. Large quantities of fish are packed here for foreign markets. A typical dock scene is shown in Fig. l. These hardy fisherwomen often toil from 6 o’clock in the morning to 10 o’clock at night. The abundance of fish makes the local cost low.

It would be difficult to find examples of womanhood combining a higher degree of physical perfection and more exalted ideals than these weather-hardened toilers. Theirs is a land of frequent gales, often sleet-ridden or enshrouded in penetrating cold fogs. Life is full of meaning for characters that are developed to accept as everyday routine raging seas and piercing blizzards representing the accumulated fury of the treacherous north Atlantic. One marvels at their gentleness, refinement and sweetness of character.

The people live in what have been called black-houses. These are thatched-roof dwellings containing usually two or three rooms. The walls are built of stone and dirt usually about 5 feet in thickness. There is usually a fireplace and chimney and one or two outside doors and few windows. The thatch of these houses plays an important role. It is replaced each October and the old thatch is believed by the natives to have exceptional value as a special fertilizer for the soil, because of its impregnation with chemicals that have been obtained from the peat smoke which is seen seeping through all parts of the roof at all seasons of the year. Peat fires are kept burning for this explicit purpose even when the heat is not needed. This means that enormous quantities of peat are required to maintain a continuous smudge. Some of the houses do not have a chimney because it is considered desirable that the smoke leave the building through the thatched roof. Not infrequently is smoke to be seen rolling out of an open door or open window. Fortunately the peat is so abundant that it can easily be obtained in almost limitless quantities nearby. The sheep that roam the heather-covered plains are a small, black-faced variety with great hardihood. They provide a wool of specially high quality which, incidentally, is the source of our famous Harris tweeds which are woven in these small black-houses, chiefly on the Isle of Harris.

We are particularly concerned with the people of early Scotch descent who possess a physique that rivals the product of any place in the world. They are descendants of the original Gaelic stock whose language is their language today, and the only language that a large percentage of them can speak. This island has only one port which means that most of the shoreline still provides primitive living conditions as does the central part of the island. It was a happy surprise to find such a high type of manhood and womanhood as make up the occupants of these rustic thatched-roof homes, usually located in an expanse of heather-covered treeless plains. It would be hard to visualize a more complete isolation for childlife than many of these homes provide which makes one marvel at the refinement and splendid intelligence and strength of character of these rugged people. They resent, and I think justly so, some critical and uncomplimentary references to their homes which have been given the name of “black-houses.” Several that we visited were artistically decorated with clean wall paper and improvised hangings.

One would expect that in their one seaport town of Stornoway things would be gay over the week-end if not boisterous with between four and five thousand fishermen and seamen on shore-leave from Saturday until midnight Sunday. On Saturday evening the sidewalks were crowded with happy carefree people but no boisterousness, drinking or vulgarity were to be seen. Sunday saw the people going in throngs to their various churches and all in a serious mood. Before the sailors went aboard their crafts on Sunday evening they met in bands in the street for religious singing and prayers for their safety on their next fishing expedition. One could not buy a postage stamp or picture card or find any place of amusement open on Sunday, nor could a taxi be hired or a newspaper purchased on the street. Everybody has reverence for the Sabbath day on the Isle of Lewis. Every activity is subservient to their observance of the Sabbath day. No one could witness their simple devotion to their ideals without profoundly honoring their strength of character. In few places in the world are moral standards so high, or is the spirit of love and charity and brotherly regard more beautifully expressed than in their kindness to strangers and the high esteem in which womanhood is held. One wonders if the bleak winds which thrash our north Atlantic from the Labrador and Greenland coasts have not tempered the souls of these people to create in them higher levels of nobility and exalted expression. These people are on the outposts of the western fringe of the European continent.

Just as one sees in Brittany on the West coast of France, the prehistoric druidical stone forests marking a civilization that existed so far in the past as to be without historic records except in its monuments, so too does one find here the forest of granite slabs in which these sturdy prehistoric souls worshipped their divinities before these people were crowded into the sea by the westward moving hordes. When one realizes the distance from which these stones had to be transported, probably at least twenty miles over difficult terrain, one can appreciate the task, particularly if one calculates their size according to the depth to which they must be buried in order to stand so erect and tall to this day.

We are concerned primarily, however, with the physical development of the people and particularly with their freedom from dental caries. One has only to see them carrying their burdens of peat or observe the ease with which the fisherwomen on the docks carry their tubs of fish back from the cleaning table to the tiers of packing barrels to be convinced that these people have not only been trained to work but have physiques equal to the task. The studies of these people included dental examinations, photographs, obtaining samples of saliva for chemical analysis, obtaining mouth cultures, detailed clinical records, samples of food for chemical analysis, and detailed nutritional data.

Communication between the various islands is difficult in many of these districts, because more complete isolation than some of them provide would be hard to find. We tried to get to the islands of Taransay and Scarpa on the west coast of the Isle of Harris but were unable to obtain transportation which can only be done with seaworthy special crafts. The crafts will only undertake the passage at certain phases of the tide and direction of the wind. On one of these islands we were told the growing boys and girls had exceedingly high immunity to tooth decay. Their isolation was so complete that a young woman of about 20 years of age who came to the Isle of Harris from Taransay Island had never seen milk in any larger quantity than drops. There are no dairy animals on that island. Their high immunity is provided by their oat products and fish and limited supply of vegetables. Lobsters and flatfish are important items in the diet. Fruits are practically unknown.

There are some lessons to be learned from these communities for surely this section would suffer from dental caries if either a preponderance of alkaline or a liberal vitamin C were requisites to a high immunity to tooth decay. Surely few diets can be found more acid-producing than the oat products and fish that are nearly the sole source of nutrition here.It was necessary sometimes for us to engage skilled seamen and their crafts to make a special trip to take Mrs. Price and our interpreter and me to some of these isolated islands. These seamen watch critically the tide and wind and sky and determine the length of time it will be safe to travel in a certain direction because of the speed of the running tide and the periodic change of the wind. Some of these islands are isolated by severe weather conditions for many weeks at a time.

These islands have been important in the whaling industry even until recent years. We visited a whaling station on the Isle of Harris, not active at this time, where the monsters of the sea were towed into a deep bay. The marketable products were collected for distribution.

In the interior of the Isle of Lewis the teeth of the growing boys and girls had a high degree of perfection with only 1.3 teeth out of every hundred examined that had even been attacked by dental caries. It will be interesting to see the figures obtained from an analysis of their nutrition and of their saliva which will be discussed in the succeeding installment of these studies.

An important part of the study of these islands consisted in critically observing what occurred at the fringe of civilization. A typical cross section of the residents of their seaport town of Stornoway were seen assembled on the docks to greet the arrival of the evening boat, the principal event of the community. This group was made up largely of adult young people. In a count of a hundred persons appearing to be between the ages of 20 and 45, twenty-five were already wearing artificial teeth and as many more would have been more presentable had they too been so equipped. Dental caries was rampant in the modernized section of Stornoway. Since an important part of these studies involved a determination of the kind and quantities of foods eaten, it was necessary in practically every place studied to visit the sources available for purchasing foods. In Stornoway one could purchase angel food cake, white bread as snow white as in any community in the world, many other white flour products, and canned marmalades, canned vegetables, sweetened fruit juices, such as jams, confections of every type filled the store windows and counters. These foods probably made a great appeal to the palates of these primitive people both because of their variety and their high sugar content. The difference in physical appearance of the childlife of Stornoway from that of the interior of the Isle of Lewis is more striking than one would conceive possible, nor indeed were the destructive effects limited to this seaport town. We found a family, for example, on the opposite coast of the island where the two boys shown in Fig. 2 resided. One of these brothers had excellent teeth and the other had rampant caries. They ate at the same table. The older boy with excellent teeth was still enjoying primitive food of oat meal and oat cake and sea foods with some limited dairy products. The younger boy, shown at the left, had rampant tooth decay. Many teeth were missing including two in the front. He was having his food largely sent in by mail from the distant port. He insisted on having white bread and jam and highly sweetened coffee and also sweet chocolates. His father told me with deep concern how difficult it was for the boy to get up in the morning and work, whereas his older brother was physically so much stronger.

One of the sad stories of the Isle of Lewis has to do with the recent rapid progress of tuberculosis. The younger generation of the modernized part of the Isle of Lewis is not showing the resistance to tuberculosis that their ancestors did. Indeed a special hospital has been built at Stornoway for the rapidly increasing tuberculous patients, particularly for women between 20 and 30 years of age. The superintendent explained to me with deep concern the rapidity with which this menace was growing. I was surprised to find that little consideration was apparently being given to the change in nutrition as a possible explanation for the failure of this generation to show the defense of previous generations against pulmonary tuberculosis. Formerly it was rare. In this connection much blame had been put on the housing conditions, because it was thought that the thatched-roof house with its smoke-laden air was an important contributing factor notwithstanding the freedom from this disease in former generations.

Large numbers of the people had been induced with the financial assistance of the British Government to build modern homes and abandon the open peat fireplace and thatched roof. I was told that the incidence of tuberculosis was frequently the same in the modern homes as it was in the thatched-roof homes. It was of special interest to observe the attitude of mind of the native with regard to the thatched-roof house. Over and over we saw the new house built beside the old one and the people apparently living in the new one but still keeping the smoke smudging through the thatch of the old thatched-roofed house. When I inquired regarding this I was told by one of the clear thinking residents that this thatch collected something from the smoke which when put in the soil doubled the growth of plants and the yield of grain. He showed me with keen interest two patches of grain which seemed to demonstrate the soundness of his contention. I brought some of this thatch and grain with me for chemical analysis. The results have been spectacular and will be discussed in another communication.

I was particularly interested to study the growing boys and girls at a place called Scalpay in the Isle of Harris. This island is rocky and has only small patches of soil for available pasturage. For nutrition the children of this community were dependent largely on oat meal porridge, oat cake and sea foods. An examination of the growing boys and girls disclosed that only one tooth out of every hundred examined had ever been attacked by tooth decay. Their physical development was excellent as will be shown later.

This is in striking contrast with the children of the hamlet of Tarbert which is the only shipping port on the Isle of Harris. This is the principal export port of the famous Harris tweeds which are manufactured on looms in the crofters’ homes. Of every hundred teeth examined in these Tarbert children there was an incidence of 32.4 teeth already attacked by dental caries. The distance between these two points, Scalpay and Tarbert, is not more than ten miles and as both are on the coast they have equal facilities for obtaining sea foods. Only the latter, however, has access to modern foods since it supports a white bread bakery store with modern jams and marmalades and canned foods of various kinds. In studying the tragedy of rampant tooth decay in the mouth of a young man I asked him regarding his plans and he stated that he was expecting to go to Stornoway about sixty miles away in the near future, as there was a dentist there and he would have all his teeth extracted and plates made. He said there was no use in having any teeth filled because he would have to lose them anyway since that was everybody’s experience in Tarbert. The same condition prevailed among the young women.

We made a journey to the extreme western part of the Isle of Harris hoping to engage transportation to the Island of Scarpa to which I have referred, but the sea was too rough and the trip could not be made. I was advised that only a few years ago there was not a single decayed tooth among the growing boys and girls of this island, but now, since the establishment of weekly postal service and commerce, dental caries had become rampant. On inquiry we found that modern foods including refined flours were displacing the native natural foods of oat and fish products.

Through the department of dental inspection for north Scotland I learned of a place on the Isle of Skye, Airth of Sleat, in which only a few years ago there were thirty-six children in the school and not one case of dental caries in the group. My examination of the children in this community disclosed two groups, some living largely on modern foods and the other group living on primitive foods. Those living on primitive foods had only 0.7 teeth that had ever been attacked by caries per hundred examined, while those in the group living on modern foods had 16.3 or twenty-three times as many as those on primitive foods.

This community living near the sea had recently been connected with the outside world by daily steamboat service which delivered to the people modern foods of various kinds and with it we found there had been established a modern bakery and facilities for purchasing the canned vegetables, jams and marmalades. This district was just in the process of being modernized.

I examined teeth of several people in the seventies and eighties and except for gingival infections with some loosening of the teeth almost all of the teeth were present and there was little evidence that dental caries had ever existed. The elderly people were bemoaning the fact that the new generation that was growing up did not have the health of former generations. I asked what their explanation was and they pointed to stone grinding mills which they said had ground the oats for oat cake and porridge for their family and preceding families for at least two hundred years. Though they prized them highly the plea that they would be helpful in educational work in America induced them to consent to selling them. Two of these old people are shown with their son in Fig. 3 sitting in front of an abandoned primitive home with a pair of mill stones beside them which I brought back with me. Note the wonderfully fine physique of the son. He told us with great concern of the recent rapid decline in health of the young people of this district.

A splendid illustration of the promptness with which long established customs are abandoned when commerce makes modern food products available is seen in Fig. 4, in which is shown two views of an ahandoned grist mill on the West Coast of the Isle of Lewis. The power had been provided by a small stream which rotated one stone on another. This mill was used for grinding oats. It quickly went into disuse when the grain products as produced by the modern steel roller process became available by import.

This one-time well populated island, the misty Isle of Skye, still has one of the finest of the famous old castles built by the stalwart men of the Dunvegan clan. This castle figured in the romantic life of Prince Charlie. The castle equipment still boasts the grandeur of a past glory. Among the relics is a horn which measured the draft to be drunk by a prospective chieftain before he could aspire to the leadership of the clan. He must drink its contents of two quarts without stopping. Again the character of that race is reflected in the fact that although a bounty of thirty thousand pounds was placed on the head of Prince Charlie for anyone who would reveal the place of his hiding, which many knew, not one could be found who would betray him.

On my return from the Outer Hebrides to Scotland I was concerned to obtain information from government officials relative to the incidence of tooth decay and the degenerative diseases in various parts of north Scotland. I was advised that in the last two generations the average height of Scotch men had in some parts decreased 4 inches and that this had been coincident with the general change from high immunity to dental caries to a loss of immunity in a large area of this general district. A study of the market places revealed that a great deal of the food was shipped into the district in the form of refined flours and canned goods. There were few herds of dairy cattle to be seen. It was explained that even the highland cattle did not do so well as formerly on the same ranges.

As one proceeds from the north of Scotland southward to England and Wales there is a marked increase in the percentage of persons wearing artificial restorations or in need of them. In several communities studicd this reached 50 per cent of adults over 30 years of age. An effort was made to find primitive people in the high country of Wales, but without success. We were advised that about the only place that we would be likely to find people living under primitive conditions would be on the Island of Bardsey off the northwest coast of Wales. This is a rock-bound and stormy island with the decadent walls of an old castle and a community made up largely of recently imported colonists whom we were advised had been taken to the island to repopulate it. There is considerable good farm land but limited grazing stock. Formerly the island with the fishing around it had produced the foods for its inhabitants. These sources of natural foods have been largely displaced with imported white flour, marmalades, jams, and canned goods. We found the physical condition of the people poor, particularly that of the growing boys and girls. Tooth decay was rampant, so much so that 27.6 out of every hundred teeth examined had already been attacked by dental caries in the growing boys and girls. It was even active in three year old children. These children will be referred to later in connection with the studies made of facial deformities associated with these nutritional disturbances. From a conference with the Director of Public Health of this district I learned that tuberculosis constituted an enormous problem not only for the people on this island but for many districts of northern Wales. This was ascribed to a lowered defense of the people from causes unknown. It had been noted that persons with rampant tooth decay were more susceptible to pulmonary tuberculosis.

While on the Island of Bardsey I Inquired as to what they thought was the cause of such extensive tooth decay as we found. I was advised that they were familiar with the cause and that it was due to close contact with the salt water and salt air. When I asked why many of the old people who had lived by the sea all their lives in some districts still had practically all their teeth and had never had tooth decay no explanation was available. This, they said, was the reason that had been ascribed in answer to their inquiries. A visit to the school dental clinic of Swansey in southern Wales revealed an active service splendidly organized but which consisted almost exclusively, as explained by the operators, in extractions. I was particularly concerned to know whether the depression of this formerly busy center was affecting the people that were poor more than those that had means. I was interested to be advised that the children of the men living on the dole, although they had extensive tooth decay were not so seriously affected as the children of the better classes.

The Director of Public Health of that city and district was concerned regarding the progressive increase in the incidence of dental caries such that the teeth of almost every person were seriously attacked, making artificial restorations a common occurrence in adults.

Unfortunately space does not permit including here detailed information relative to the association of physical deficiency expressions, including facial deformities with the incidence of dental caries and the relation of both to nutrition. This has been discussed in another communication and will be reviewed in the next installment. The chemical analyses of the samples of saliva obtained from these people produced important data which will also be reported.

The fifth installment of these studies will deal with practical procedures for the nutritional control of dental caries.