Tuberculosis Among the Nebraska Winnebago A Social Study on an Indian Reservation By Margaret W. Koenig, M. D. With Illustrations and Charts m Published by the Nebraska State Historical Society Lincoln, Nebraska Cfce ittbrarg of m Ontoersitg of iSortb Carolina (EntiotoeD bp W$t ^Dialectic 2? vo rO to THE LIBRARY OF THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL ENDOWED BY THE DIALECTIC AND PHILANTHROPIC SOCIETIES RC313 .A55 K6 UNIVERSITY OF N.C. AT CHAPEL HILL 10002171267 This book is due at the LOUIS R. WILSON LIBRARY on the last date stamped under "Date Due." If not on hold it may be renewed by bringing it to the library. DATE nIrT DUE RET DATE DPT DDE KtT - MAR 2 «5 f Iff HP fit. * 199?' -1 „ , £ - _ Tuberculosis Among the Nebraska Winnebago A Social Study on an Indian Reservation By Margaret W. Koenig, M. D With Illustrations and Charts Published by the Nebraska State Historical Society Lincoln, Nebraska 1921 KG Copyright 1921 By Nebraska State Historical Society Lincoln, Neb. »ri|N FT«. CO.. UNIVERSITY PLACE. NilK. INTRODUCTION The Winnebago is one of the tribes known longest and least by white men. Upon the Omaha, Pawnee, Cheyenne and Kiowa tribes there is an extensive literature, represent- ing years of close contact and study by scientific scholars, but neither in Nebraska nor in Wisconsin has the Winne- bago received similar attention. No careful scientific study of the Winnebago language and its relationship to other Indian tongues had been made until the preliminary work of Dr. Paul Radin of Columbia University about ten years ago. The exiled wanderings of the Winnebago from their old Wisconsin-Minnesota home to their final Nebraska location make a story as romantic and tragic as that told by Helen Hunt Jackson in Ramona. No further emigration is possible for the tribe upon this planet. It must survive or perish where it now is. In Nebraska its fate is closely connected with that of its white neighbors. The battle for the life of the Winnebago tribe is therefore a battle for Nebraska. This study of the Nebraska Winnebago by Dr. Margaret W. Koenig is one of vital importance to our state. The Ne- braska State Historical Society gladly welcomes it to its list of publications. Most of the photographs used in the illustrations are from the camera of Frank H. Shoemaker, one of the most success- ful artists in dealing with nature. A special winter trip to Winnebago was made for some of them. July 20, 1921. Addison E. Sheldon, Supt. Nebraska State Historical Society. do FOREWORD , The seedthought for this study originated with Mrs. K. R. J. Edholm, executive secretary of the Nebraska Tubercu- losis Association. It was conducted in co-operation with the Department of Sociology of the University of Ne- braska, and the field work was financed by the National Tuberculosis Association. The purpose was to ascertain by direct investigation, first-hand facts and conditions pertain- ing to Winnebago Indian life, with particular reference to tuberculosis. To this end a field study was made on the reservation during the months of July and August, 1919. It is hoped that the publication of this study may arouse public interest to such an extent that substantial assistance will be given the government in carrying out its constructive health program for the physical welfare of our Indian friends. My deep appreciation and thanks are extended to all those who have entered into the spirit of the work and have fur- nished information and other aid. A large share of the suc- cess of this report is attributed to the government and mission workers on the reservation and the Indians, who re- sponded so willingly and cheerfully in the promotion of the work, and without whose generous help the collection of this data would not have been possible. Especial recognition is due Mrs. Addie Boucher, Winnebago Indian nurse, and Miss Anna Berkenpas, nurse and field-worker for the Dutch Re- formed Mission, for their invaluable personal services ; and Superintendent C. D. Munro, who placed the records of ♦ VI Nebraska State Historical Society the agency at my disposal, and extended other courtesies. Grateful acknowledgment is made to the Commissioner of Indian Affairs for his co-operation; to the Nebraska State Historical Society for providing the illustrations; to Harry H. Laughlin of the Eugenics Record Office, Cold Spring Harbor, Long Island, New York, and Dr. H. J. Lehn- hoff of 'Lincoln, Nebraska, who read the manuscript of the following pages and gave the benefit of their criticism. I am under the deepest obligation to Dr. Hattie Plum Will- iams, Associate Professor of Practical Sociology in the University of Nebraska, for her personal interest and in- valuable assistance in the preparation of this material. Lincoln, Nebr., July, 1921. Margaret W. Koenig. CONTENTS Chapter I. Historical and Sociological Background. 1. The Winnebago Tribe 1 2. The Winnebago in Nebraska 4 Chapter II. Incidence of Tuberculosis. 1. Basis of Data .. 17 2. Mortality and Morbidity Rates 19 3. Classification of Tuberculosis Cases 21 Chapter III. Factors Among the Winnebago Predispos- ing to Tuberculosis. 1. Home Sanitation . 31 2. Social Customs 35 3. Use of Stimulants 36 4. Allied Diseases 38 Summary , ... 42 Appendix — Family Distribution of Tuberculosis 46 TABLES Page I. Showing Movement of Population, 1909-1919 5 II. Showing Distribution of Families and Permanent Houses 8 III. Showing Distribution of Population per Degree of Blood 9 IV. Showing Number of Winnebago Employed in Gain- ful Occupations, September, 1919... 14 V. Mortality and Morbidity from Tuberculosis among Winnebago, 1909-10 to 1918-19 .. .Opposite 20 yi. Showing Age Distribution of 237 Cases of Tuber- culosis among the Winnebago, 1909-1919..... 22 VII. Forms of Tuberculosis in 237 Cases among the Winnebago, 1909-1919... 24 VIII. Showing Number of Deaths from Tuberculosis by Seasons, 1909-1919 32 \ VIII Nebraska State Historical Society CHART AND MAPS Page Location of Winnebago Reservation in Nebr Opposite 4 Distribution by Age Periods and Sex Groups of Winnebago, 1919, 1913 Opposite 8 Thurston County Showing Winnebago Reser- vation . ; _ Opposite 48 ILLUSTRATIONS Page Winnebago Indian Agency Frontispiece Upper — Winnebago Mother and Child { facing 10 Lower — Mending Day J. " Winnebago Farm Buildings facing 13 Types of Winnebago Travel facing 15 Winnebago Indian Graves facing 16 Indian Hospital and Grounds facing 18 An Indian Hogan.. ....facing 26 Modern Winnebago Homes facing 31 Interior Views facing 32 A Sick Winnebago Asleep ....facing 33 Mescal Buttons (Peyote) . facing 36 Upper — Native Tent Abode ] Middle — Primitive Bark Hut y ..facing 40 Lower — Summer Quarters J CHAPTER I HISTORICAL AND SOCIOLOGICAL BACKGROUND 1. The Winnebago Tribe The Winnebago are a branch of the great Siouan linguis- tic family of North American Indians. 1 They have been known to the whites since about 1634 when they were lo- cated in the timber and lowlands bordering on Lake Winne- bago in east central Wisconsin. From the nature of their habitat they were forest Indians, living in a more or less settled state. Their dwellings were permanent bark or mat wigwams. They engaged in agriculture, corn being the chief product, and in fishing and trapping. Their activities as fur traders figured prominently in the early history of the locality where they had lived for generations in comfort and happiness. They were at this time described by travelers and missionaries as a "prosperous people," a fine-looking and stalwart race. After two centuries of undisturbed residence misfortune overtook them. They had suffered the usual tragedies of Indian tribes. Several times their ranks had been decimated and their tribal strength reduced by war, famine, and dis- ease. In their contact with unprincipled and heartless whites — licensed traders and liquor dealers — they had ex- perienced, now and again, the loss of "their money, their goods, their food, their clothing, their virtue, and their health." Finally the rapid advance of white settlers follow- ing the Black Hawk War (1832) had resulted in the forced, sale of their lands to the United States in 1837. But their peculiar misfortune lay in the fact that for a generation 'The chief sources for the history of the Winnebago are: Report of Commissioner of Indian Affairs for the years 1845, 1846, 1847, 1862, 1864, 1865, 1867 and 1869; Handbook of American Indians; Lawson, P. V. "The Winnebago Tribe," in Wisconsin Archeologist, VI, 78-114. 2 Nebraska State Historical Society following the forced migration from their native habitat, the Winnebago were without a permanent home. Settled by the government in no less than five different locations they finally separated voluntarily, some throwing themselves upon the charity of a neighboring tribe and others wander- ing back to their original haunts. The first removal was made under protest, the tribe re- pudiating the sale of their lands and claiming that the en- voys were not authorized to arrange for their transfer. In spite of their objections, part of the tribe was forcibly moved to their new location in northeastern Iowa in 1840. The open, timberless country was a distinct change from their forest home and there was much suffering from im- proper housing, insufficient food and disease. In 1846 this group was removed to a reservation at Long Prairie, Minne- sota. Again the location proved unsuitable and ill-adapted to their native needs and most of them scattered through- out the state. In 1855, 1300 Winnebago, some from Wis- consin and some of those scattered throughout Minnesota, were placed on a reservation at Blue Earth, Minnesota, a location of their own choice and most highly valued by them. Here, in an environment suited to their nature, they quickly began to recover and to regain some of their former pros- perity. But misfortune pursued them in the guise of the terrible "Sioux Massacre" of 1862. Although the Winnebago took no part in the affair, and even though they offered their ser- vices in punishing the Sioux, the frightened inhabitants of Minnesota demanded the removal of all Indians. This was provided for by a special Act of Congress, February 21, 1863, which designated Crow Creek, near Pierre, South Dakota as their reservation. The removal was carried out in a most cruel manner. An official of the Indian service describes it thus in a report to the Commissioner of Indian Affairs: 1 "Hurried from their comfortable homes in Minnesota, in 1863, almost without previous notice, huddled together on 'Report of the Commissioner of Indian Affairs for the year 1865, 410. Tuberculosis Among the Winnebago 3 steamboats with poor accommodations, and transported to the Crow Creek agency, in Dakota Territory, at an ex- pense to themselves of more than $50,000, they were left, after a very imperfect and hasty preparation of their new agency for their reception, upon a sandy beach on the west bank of the Missouri river, in a country remarkable only for the rigors of its winter climate and the sterility of its soil, to subsist themselves where the most frugal and in- dustrious white man would fail five years in every six to raise enough grain upon which to subsist a family." In addition to physical hardship the Winnebago suffered mental distress. They believed that their loyalty to the government should have entitled them to consideration and kind treatment. When they became convinced that public opinion demanded their leaving the home to which they had become attached, they were assured by the government that it would place them in a location as favorable as the one which they were leaving. Not only did it fail to keep its promise to them in this, but it stupidly placed their en- emy, the Sioux, upon the same reservation to be occupied jointly by the two tribes. Broken in health and in spirit, the Winnebago faced the alternative of abandoning the agency or dying from cold and starvation. They chose to leave and in the winter of 1863-64 many made their way to the Omaha reservation in northeast Nebraska, arriving there in a destitute condition.' A large number died of cold and hunger on the way. Out of 2000 taken to Crow Creek, over 1200 had reached the Omaha reservation by September, 1864. Many, through fear of the Sioux, fled from Crow Creek and wandered about 'Thomas L. Sloan, President of the Society of American Indians, says of their arrival: "When they came to this location they were affected with tuberculosis, syphilis and other diseases. Many of them had scrofulous sores on their faces, necks and bodies. At the time they came here and for many years after, their necessities were such that they went about the country picking up domestic animals that had died and used the flesh for food. It was particularly noticeable that as soon as they set to work farming and procured means from their labor they improved in their habits, health and general appear- ance." 4 Nebraska State Historical Society through the white settlements. Most of the remainder scattered into their old haunts in Wisconsin among their native woods and streams where, without a reservation and in defiance of several attempts on the part of the govern- ment to remove them, they remain to this day. 4 2. The Winnebago in Nebraska As suggested above, the Winnebago tribe of Indians con- sists today of two groups, the Wisconsin and the Ne- braska. It is of the latter group that this study is made. These Winnebago are located on a reservation in Thurston County, Nebraska, twenty-four miles southwest of Sioux City, Iowa. This reservation was secured for them March 6, 1865, through the negotiation of a treaty made by the United States government with the Omaha tribe who then owned the land. It comprises a strip about seven miles wide and twenty-four miles long, extending east and west and traversed from north to south by creeks bordered with abundant timber. Forest-clad hills and secluded fertile valleys are numerous. The Missouri river flows along the eastern edge. There are 327 miles of highway. The Winne- bago being forest Indians, the general topography of this location is well adapted to their native environment. The Winnebago Indian Agency nestles in a beautiful valley near the center of the reservation. Here are grouped the government buildings, including the central office or administration building, the commissary, laundry, hospital, and homes of the employees. Across the creek from the agency is the Dutch Reformed Mission which maintains dormitories for the Indian children attending its school. A mile and a half distant is the village of Winnebago where, on prominences overlooking the countryside, are located the Catholic and Episcopal Missions. 4 According to the Handbook of American Indians, in 1910 there were 1063 Winnebago in Nebraska and 1270 in Wisconsin. Tuberculosis Among the Winnebago 5 According to the agency records, there were 1078 Winne- bago enrolled in 19 19. 5 In addition to the Indian population, the reservation contains a number of whites who lease the Indian land, maintain business enterprises in the village, or are employed about the agency. The proportion of whites is growing rapidly, while the Indian population is stationary. The following table, arranged from the local Table I. Showing Movement of Population, 1909-1919* YEAH 1909- 1910- 1911- 1912- 1913- 1914- 1915- 1916- 1917- 1918- 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 Male £85 593 579 582 Female 501 506 507 496 Total 1057 1086 1077 1099 1090 1098 1096 1105 1086 1078 Incr. or Deer, over Preced- ing Year +29 — 9 +22 — 9 ;+ 8 — 2 + 9 —19 Births 57 52 36 38 31 39 32 21 26 Deaths 39 43 3tf 30 31 40 51 44 Incr. or Deer, of Births over Deaths + 18 + 9 — 1 + 8 0 — 1 —30 —18 Total 332 315 census records, shows the movement of the Indian popu- lation during the past decade. In 1919 there was an in- crease over 1910 of only twenty-one inhabitants, every al- ternate year of the decade showing an actual decrease in the Indian population. The birth and death records, though they do not check with the census, corroborate this general tendency toward tribal decay. The seven years for which \>oth data are given show an excess of fifteen deaths over B The census for 1919 shows only 1068 names: 578 males and 490 females. A recent examination of other documents by agency officials disclosed the names of ten children, under five years, omitted from the roll. The revised figures are substituted in the table and used as a basis for computation throughout the. study. "Winnebago Indian Agency, Local Census Records, 1909-1919. 6 Nebraska State Historical Society births/ Incomplete as the records probably are, they show an abnormally high death rate, the average for the eight years being 36.2 per 1000 or two and one-half times the rate for the registration area of the United States. The birth rate for the same period, computed on the official data, is 34.4 per 1000. While this is a high birth rate, it is ob- viously too low, since it does not permit even the slight in- crease shown in the enrollment. There are no available records by which to trace the cause for the very high death rate and the resulting fact that the population is stationary ; but every indication points to a high infant mortality as one of the most important factors. An agency official states that she knows of but two Indian mothers who have not lost one or more of their children. In spite of a high birth rate, the Winnebago family is small, having less than two children per family. 8 Many instances were found in which a mother had borne ten to twelve children, and several cases were found in which seventeen to twenty births had occurred. In most of the latter, very few children are living at present, half of them having died in infancy. 9 The distribution of the population according to sex and age is a significant factor. In Table I is shown the total male and female population for four years out of the de- cade. There is a decided excess of males, the number per Reservation workers claim that the vital statistics record is in- complete for these reasons: Many Winnebago mothers go unattend- ed at childbirth, and frequent deaths occur on the reservation which are not reported to the local office. Although these Indians have adopted modern burial customs, only occasionally is a burial permit issued. 'Cf. below, 8.- •A local physician believes that much of this mortality is due to error in diet. She says that the Indian mother's unreasoning love for her children causes her to nurse her babies incessantly and to feed them everything, especially during the hot weather. Breast feeding is universal. The Indian mother as a rule is well able to nurse her child. But one instance of a bottle fed baby was met with in this study. When ill they are given little medicine because of its unpal- atableness — Indian herbs and barks being preferred.. They will afford these little ones relief by giving enemas, using the leg of a chicken bone and a cow bladder as a syringe. Frequent bathing of the babies is a common practice among the Winnebago mothers. Tuberculosis Among the Winnebago 7 100 females varying from 114.2 to 117.3 while for the In- dian population of the entire United States there are only 103.5 males per 100 females. 10 The distribution of the Winnebago population by age periods in 1919 shows some curious irregularities. The most striking is the small proportion under five years of age and the large percentage over sixty-five years. In a popula- tion which increases only genetically this is not a normal condition. Allowing for the careless recording of birth- days and the tendency among primitive people to state one's age in terms of the future, instead of the past, there is still an unusually small proportion of children under five. This is partially accounted for by an epidemic of measles* in 1915. The autumn was extremely cold, and as young children were not kept in during their illness, most of the smaller ones developed pneumonia and died. The record for the fiscal year 1915-16 shows 15 out of 40 deaths, or 37.5 per cent to be under three years of age. Again in 1917-18, 20 deaths out of 51, or 39.2 per cent, were under three years. In addition to the unusual proportion of deaths among small children during this period, there is the increased number of stillbirths reported by volunteer workers within the past five years. 11 These factors are probably the most important ones in accounting for the unusual phenomenon shown in the age distribution for 1919; viz., that the proportion of the population under five years (11 per cent) is smaller than the proportion in either of the next two age groups. In order to determine the distribution for a normal period, the population for 1913 was analyzed. This year was chosen because it preceded the war, was more than five years dis- tant from the data for 1919, and because in that year a per capita payment was made by the government to the Winnebago, and hence the probabilities of a careful census "Thirteenth Census, Abstract, 97. "As a rule, stillbirths and the births of infants who die when but a few hours old are not reported on the reservation. The recent increase in both these groups is thought by some to be due to the in- crease of venereal diseases. 8 Nebraska State Historical Society were greater. The population for 1913 shows 13.9 per cent under five years, 11.9 per cent between five and nine years, and 7.2 per cent between ten and fourteen years. This is more nearly what one would expect, although the fact that the next three age groups are larger than the group from ten to fourteen suggests a former sweeping-off of children similar to the one within the past five yars. The average number of persons per family among the Winnebago is small. In 1919, the 1078 persons enrolled were distributed among 291 families, with an average of Table II. Showing Distribution by Families and Permanent Houses 12 Year Total Population Families Number Living in Permanent Houses 1909-1910 1057 1086 1077 1099 1090 1098 1096 1105 1086 1078 193 0-1911 1911-1912 212 249 256 256 248 1912-1913 1913-1914 1914-1915 1915-1916. 1916-1917 1917- 1918 1918- 1919 291 291 258 262 but 3.7 persons per family. The great majority of these (262 families) live in permanent houses, which are slowly but steadily increasing. The remaining 29 families, or ten per cent of the total, either live with relatives and friends or travel about from place to place. The Winnebago show only slight intermixture with other races or with other tribes. In a total of 1463 individuals whose family connection was traced, there had occurred ten unions with Frenchmen, eight with other whites, and twelve with Indians of another tribe. These intermarriages "Winnebago Indian Agency, Local Census Records, 1909-1919. Distribution by Age Periods and Sex Groups of the Winnebago S0 07 2.0 60 6* 55 j z\ \*.* /0 \*0 rZf Z0 30 1 If ~Y£7 \0.6 3 J ? S f * J J / <7/SJ'*J-4 7 14 12.96 November 5J Total 108 108 99.98 The Winnebago's ignorance of hygiene and their careless- ness with regard to sanitary principles prevent their profit- ing from the advantages provided for them. The women show little ability in making the homes comfortable and healthful, wearing apparel, bedding, and kitchen utensils Interior Views Tuberculosis Among the Winnebago 33 being heaped on the floor against the wall. 51 The furniture used is insufficient to provide system and order. "The women are always washing but do not know how to keep things clean. For instance, a tub of water is kept constantly at hand, into which the clothes are placed and washed as needed. They do no ironing, merely smoothing the clothes with their hands." Since no heat is applied either in wash- ing or pressing, the clothes cannot be so well protected from disease as under a different method of cleansing. The per- sonal clothing of the Indians is kept cleaner than their houses ; yet they are more careless about their hand towels than about their dish towels. The use of utensils in common is almost everywhere the practice. The common drinking cup and the use of the un- washed dishes of the tuberculous by small children are im- portant factors in the spread of infection. The use by the whole family of a common dish and spoon is quite customary. Also, standing about the house may be several cans of store products in which a common spoon serves for the family and visitors. The smoking of the "peace pipe" in which a lighted pipe is passed, uncleansed, from mouth to mouth, provides a direct source of infection from the disease. In addition to the common use of eating utensils, sleeping facilities are widely shared. Old and young, sick and well alike, sleep in the same beds, as do those affected with active tuberculosis, for the sick are not isolated in any way, and consumptives live in the midst of their families. The typical way for sick Winnebago to sleep is with the bed coverings drawn over their faces. The moisture from the exhaled breath, and perhaps direct expectoration, causes contamination and furnishes a prolific source of infection as "these bed-clothes are seldom changed, aired or washed." Pallets on the floor provide sleeping accommodations for the many relatives and visitors. 61 Numerous homes were found in fair condition, and a few were very well kept. 34 Nebraska State Historical Society The Winnebago are extremely careless about the disposal of human excreta. Promiscuous expectorating is a common practice. In many homes tin cans, used as spittoons, stand about the house all day uncovered. Only an occasional privy was found at the homes visited. Dressings from tuberculous lesions are thrown about promiscuously. One of the volunteer field workers believes that the cus- tom of giving away the personal belongings and bedding of deceased persons to those who have assisted with the burial is one of the greatest causes for the spread of tuberculosis and other diseases. She says she has seen bedding covered with thick greenish secretions given away; and that there is no attempt at sterilization, the pillows being merely aired and the blankets washed in cool water. Another worker cites a case of suppurating glands of the neck in which the secretions had seeped through the dressings upon a heavy wool sweater the child wore during its illness. After the burial this garment together with the bedding was given to a friend. An attempt by the worker to sterilize the clothing resulted in absolute refusal on the part of the Indians concerned. The Winnebago are a well-to-do people and whatever re- lation there may be between their food habits and tubercu- losis is due rather to their ignorance and social habits than to their failure to secure sufficient food. They keep very, few cows, hence use little milk. Possibly this is as much a safety to them as a hindrance on account .of the ease witn which milk is contaminated and becomes a carrier of disease. They have few gardens or very little poultry, and live largely on canned goods, meat, and bread purchased from the store. 52 "Their meals are irregular as they eat at all hours, exercising little or no control over their eating and 52 Decayed and infected teeth are very common among the young- er generation probably due to alleged "civilized" diet since, in his native state, the Indian ate food that kept them scoured. Tooth brushes are little used except by the young who are taught their merits in school. Tuberculosis Among the Winnebago 35 drinking." The dog is an important and privileged member of the household — a spoiled child with his nose in every receptacle. 2. Social Customs Social customs which have survived from primitive days interfere with regular habits of living. Each burial is the occasion for a four days' feast and "every member of the clan is in honor bound to render his services or be held in ill- repute. Religious festivals, such as the so-called mescal meetings, and the medicine dances, contribute to the general demoralization of the people. The mescal meetings are particularly vicious in their effects, while the night feasts which accompany all these ceremonies are a physical, and sometimes moral, debauch. Especially do the children suffer from these gatherings. Their having to lie around and to sleep anywhere on the ground, the change of diet, the consumption of great quantities of meat, especially pork, followed by days of famine, lower their vitality and make their resistance to disease nil. Incidentally it in- terferes with their regular school attendance and trains them in habits which hinder industry and the building up of their homes." 53 How far the unstable marriage relation is a factor pre- disposing to tuberculosis may be a question, yet it is a vital fact in Winnebago life. The primitive customs have been broken down and the restraints exercised by public opinion and a tribal leader have been cast aside, nor are American marriage laws enforced within the group. 54 No less common is the breaking of the marriage bond, "seemingly without the slightest hesitation. This loose marital relation leads to much immorality, not only among themselves but with low whites. Especially is this true of the present genera- "Summary of statements made by government employees. "April, 1913, there was enacted a law legalizing tribal mar- riages and divorces prior to that date. Revised Statutes of the State of Nebraska, 1913, p. 465. 36 Nebraska State Historical Society tion." Yet with all this ease of marriage and divorce, num- erous Indian couples remain true to each other for life. There is practically no renewal of tribal blood as marriage within the group is the rule. This may prove a factor in the physical and moral deterioration of the tribe. By reason of the many matings, the whole tribe is more or less related. Yet with all this intermarriage, but one case of the marriage of cousins was found on the reservation. 3. Use of Stimulants The Winnebago, like other Indians, have been addicted to the use of alcoholic liquors ever since their first contact with the whites. 55 Current report says that until recent years, they have been a very intemperate people. The near- ness of their reservation in Nebraska to a large and very "wet" city has undoubtedly increased the temptation and the opportunities for surreptitiously providing them with the forbidden article, but the advent of prohibition has de- creased the traffic. The use of mescal, or peyote, which has been introduced among the Winnebago in recent years, is more insidious and harmful than alcohol because it is connected with religious ceremonies, and thus receives a religious sanction. 56 Govern- ment and mission workers are vigorous in their efforts to suppress this evil, but the white population at large, ignor- ant of its effects, does nothing to discourage or prohibit its use. Mescal is a species of cactus which grows wild along the Rio Grande and southward. For many years the Indians from Arkansas to central Mexico have used it both as a drug, especially for the relief of fevers and hemor- rhages, and as a mild intoxicant. "Its use was spread among the Winnebago under the guise cf a new religion and, at the present time, more than a third of the group are addicted to it. Reservation work- ed supra, 1. E6 Cf. footnote 17, p. 11. Tuberculosis Among the Winnebago 37 ers are a unit in condemning it for its physical and moral effects. Peyote is used as a panacea for all the ills of body and soul. The drug either in its dry state or in the form of a tea is given to all who desire it, whether adult or child, Indian or white. Weekly meetings with all night sessions, under the cloak of religion, partake of the nature of lavish feasts with the result that many dollars worth of meat and other edibles are consumed. The immediate mental effects are those of an intoxication gradually accompanied by an incessant and wonderful flow of vision and music. Apparently, no unpleasant reaction follows its temporary use, as is the case with so many stimulants. Its continued use results in a physical lethargy which appears to destroy ambition and energy. The permanent effects of the drug are a weakening of the powers of resistance, particularly the heart action. The dullness of the children entering school in the fall is apparent, making them appear subnormal. As soon as the drug is eliminated from their system they are able to do work comparable with others of their class." 5T Local and agency physicians have observed that child- birth of Indian mothers addicted to the use, is attended by greatly decreased expelling power of the uterine muscles and that infants so born are lifeless and not easily revived ; that wounds do not readily heal ; that peyote users require at least twice the ordinary dose of stimulants ; and that with the fatal cases, many of whom were apparently under the immediate influence of the drug when brought to the hos- pital, the most powerful stimulants produced no results. The agency superintendent states that peyote is responsible for 100 per cent of the recent insanity among the Winne- bago. The use of tobacco is very general among both sexes. The men smoke, but few chew, while the majority of the women chew as do many of the young children of both sexes. "Summary of statements made by agency officials and mission workers. 38 Nebraska State Historical Society 4. Allied Diseases The Winnebago, like other human beings, are subject to a variety of diseases some of which predispose to the con- traction of tuberculosis. Among these latter are catarrhal conditions, influenza and venereal diseases. George B. Grin- nell in his Indians of Today, says, "A very large proportion of the northern Indians apparently have, and perhaps have had, catarrh, and seem to show a predisposition to disease of the throat and lungs/' 58 During the winter of 1918 the Winnebago suffered con- siderably from influenza and attendant pneumonia. The total morbidity from influenza among all Nebraska Indians (2834) was 861 persons or 303.8 cases per 1000 population. 89 Out of this number there were sixty deaths, twenty-five of which were among the Winnebago. The records show that the per cent of deaths among peyote users was twice as great as among the balance of the population. As to venereal disease the local records show an estimate of 20 per cent syphilitic and 40 per cent gonorrhoeal. Since the date of the above estimate a clinic has been opened at the government hospital at which routine examinations for venereal disease are to be made. Adequate treatment will be forthcoming to all found infected. The findings of the survey thus far have been kindly contributed for use in this study through the courtesy of Dr. D. A. Moore, resident government physician, who says, "As to the prevalence of venereal disease among the Winnebago Indians I beg to advise as follows: Out of 119 Wassermanns, including 100 adults and 19 children, the findings show 55 adults and 5 children 60 with positive reactions with more than 50 per cent a 4-plus positive; 45 adults and 14 children with neg- ative reactions. Other venereal infections including 39 58 Cf. also Report of Commissioner of Indian Affairs for the years 1854, 1855, 1860, 1867, 1869 and 1870. 59 £7. S. Public Health Report, XXXIV (Oct. 17, 1919), 2298-2300. 60 A11 children were under sixteen years of age with the exception of two, who were under eighteen. Tuberculosis Among the Winnebago 39 adults and 12 children show 46 positive and 5 negative. This makes a total of 170 tests representing 130 individuals, 91 of whom show some infection. Many were tested for two or three diseases and show two or three infections. In ad- dition to this we have a number under treatment diagnosed by clinical signs. To a certain extent many were selected cases, having been tested because of some suspicious cir- cumstances, but a large number are purely routine tests taken as the Indians came to the hospital as patients for other diseases and were examined for same. I feel as though I am not too generous, due to results of these tests and my observation, by saying that 60 to 70 per cent of the Winne- bago on this reservation are suffering with venereal disease either congenital or acquired." Dr. Moore further states that if all Indians found infected with venereal disease could be induced to submit to adequate medical treatment, tuber- culosis would be given a body blow. Another physician, Dr. Ralph Ross, who has been con- nected with the Indian service 24 years, says : "In the three months I was among the Winnebago and Omaha I saw more venereal disease than in the sixteen years I was among the Sioux and the six years among the Apache. These diseases are on the increase and some drastic means should be taken both for treating and preventing the spread of syphilis and gonorrhoea." The government and volunteer field workers on the reser- vation state that progress in health education is slow and difficult. The children carefully guarded by them during the school year leave at the end of the term to spend the summer months with the parents, only to return in the fall in an undernourished, anaemic and non-resistant physical condition. Difficulty with the adults too is experienced, their inherent restlessness rebelling at any long continued restraint. Particularly is this noticeable with the hospital cases. Frequently while undergoing treatment they rise from their beds and leave without warning. The citation of a few specific cases may be of interest in showing how 40 Nebraska State Historical Society little the Indian realizes the seriousness of tuberculosis, the manner of transmission or the effects of careless living, and how great is the difficulty experienced in helping them. About three and one-half years ago a field nurse found a boy of twelve years living with a number of old primitive Indians in a small, dirty, overcrowded bark hut. This boy had at that time a tuberculous knee which was being cared for by an old Indian medicine woman. She was using the ground root of milk weed as a dressing, binding the knee tightly so that drainage was impossible. They would not let the worker do anything for him. The next development was an ischio-rectal abscess. They were finally persuaded to have the child enter the hospital for treatment. He re- mained six months during which time he showed great im- provement, gaining in flesh and becoming healthy looking. At the pleading of the relatives and on promise to permit him to return, he went home for a visit and was kept there by force. He ran away but his clothes were hidden so that he would have to remain at home. The next development was pulmonary tuberculosis. About a year ago a new three room house was built which was no better as to cleanliness than the bark hut. The boy spent his time between the two homes. This family was very careless about the tuberculosis dressings, throwing them uncovered just outside the door. Never using screens, the house was filled with flies. Soon after, the mother of the boy developed pulmonary tuberculosis. Although having been warned repeatedly as to the care of the sputum they still continued to expectorate on the floor or into little cloths which were hidden under the pillow. This mother and son died last spring within a month of each other. The grandfather of this boy died of tuberculosis many years ago. The grandmother has had many cases of tuberculosis to care for in her home, most of whom were relatives. She herself presents an arrested case of phthisis bulbi (tuberculosis of the eyeball), the eye having been re- moved several years ago. Upper — Native Tent Abode — A Temporary Shelter While Visiting Friends Middle — Primitive Bark Hut — The Only One Still Remaining on the Reservation Lower — Summer Quarters — A Common Sight on the Reservation in the Summer Time Tuberculosis Among the Winnebago 41 Another case showing the facility of infection was a woman far advanced in the disease having a pulmonary, glandular and general infection of the system, who had living with her a half-brother, four years of age. At a table in a home where she was visiting she was seen to pass a chicken leg from which she had been eating to this young child. She was also using for the family sugar bowl the same spoon that she had been using in her mouth. This woman presents one of the severest cases of pulmonary tuberculosis and lymphatic adenitis on the reservation. Still she continues to live about in many homes in which there are young children. She is married to her second husband who shows an incipient pulmonary infection. The effect of careless living is shown in the case of a comely young lad of eighteen years who heedlessly roams about on the reservation and to nearby points. He pre- sents a case of active, progressive pulmonary tuberculosis, has enlarged cervical glands and healed skin lesions over the body. He carries a specific infection and has lead an im- moral life since fourteen years old. The effect of other illnesses and apparent parental neg- lect as contributing factors is shown in the case of a young girl of thirteen who was compelled to leave school because of latent glandular and pulmonary tuberculosis involving both lungs. She has had in succession smallpox, whooping cough, measles, mumps, scarlet fever, a discharging ear and infected eyes. Although in attendance at one of the govern- ment schools this child has not always had a permanent home, due to the mother's promiscuous Hying with many men, causing the child to be shifted about in various homes. To one individual 23 years of age may be traced several cases of tuberculosis because of intimate contact and close association. This young man's infection is of nine years' duration and at the present time is active to a certain de- 42 Nebraska State Historical Society gree. He has had two operations on his neck, one at 14 and one within the last year. Although showing some improve- ment he still presents a very bad lymphatic and pulmonary condition. There is at the same time a discharging sinus below the left knee. He is living in a home in which there are several cases of tuberculosis and with congested sleep- ing quarters, though this is one of the few orderly and well kept Indian homes on the reservation. 61 SUMMARY In determining the cause of tuberculosis among the Win- nebago no single factor can be isolated. "The Indians are creatures of environment. True to the instincts of their nature they like to live the free, roaming, profitless life of the Indian. To teach them the arts of civilized life and in- duce them to abandon the habits of their ancestors for ours almost amounts to a change of their nature." They were a primitive people. In their native state they were out- door individuals. They lived in the open, they worked in the open, they slept in the open. They were then a select race, as only the strongest were able to survive the rigors and hardships accompanying the wandering and wigwam life of the old Indian days. In emerging from this early tribal, nomadic life to that of civilization the Indians have been placed in an environ- ment new and unfamiliar, without protection being thrown about them. First of all then consideration must be given to the changed habits of the Indians — their present in- activity and change of diet — the transition from the old, free, active, vigorous outdoor life full of interest and ex- citement, to the indoor, inactive, shut-in modern life with food which they do not know how to prepare and to which they are unaccustomed. 61 As a result of this study of tuberculosis among the Winnebago the Nebraska Tuberculosis Association has established admission of these Indians to the State Tuberculosis Hospital at Kearney, Ne- braska. Ten Indians have been admitted, all but one (deceased) are showing favorable progress. Cf. also Superintendent's Report to Commissioner of Indian Affairs, 1920, Section 11, "Health." Tuberculosis Among the Winnebago 43 In the old days the Indians dwelt in tepees or bark lodges, with an opening at the top and the fire in the center, making ideal ventilation. When these abodes and their surround- ings became intolerable for living purposes, they were picked up and moved to fresh ground. The spot vacated cleaned up of itself. At the present day, houses have been substituted for primitive lodges without the Indians having been taught how to live in them. As the houses can not be moved as were the tepees, and nature not having the op- portunity to clean up the unsanitary conditions as they arise and multiply, the occupants continue to live on in the midst of the filth with all their native ignorance and care- lessness. Again the Indian appears to have slight powers of re- sistance to tuberculosis because the disease is new to him. Races long removed from infection are particularly sus- ceptible to disease. "Some of the white races have acquired a certain degree of resistance to tuberculosis through in- heritance (?) and almost universal infection" and have be- come to some extent immune. 62 The Indian having never experienced the disease until within recent years and not having had sufficient time for the establishing of anti- bodies to insure to any limited degree an acquired im- munity, is extremely susceptible to the disease, and when in- fection does occur it is very rapid and usually fatal. Then, too, Indians are not sensitive to suffering in them- selves or in other people, not even near relatives. This is characteristic of primitive people throughout the world. Conditions of life are hard under aboriginal environment. Old, crippled and sick persons perish. The strong and well are compelled to care for themselves. Practice of self pre- servation through centuries has formed habits of behavior toward weaker members of a tribe which surprise and shock civilized men and women. The frequent removal of the Winnebago to ill-adapted and unsuitable environments preceding their settlement in 02 Rosenau, Milton J. Preventive Medicine and Hygiene, Third Edition, 147. 44 Nebraska State Historical Society Nebraska, is a factor which of itself has been detrimental to Indian progress and physical welfare. 63 The contacts and associations with unprincipled and depraved whites, the unlawful sex relations, the abuse of intoxicants and the ready access to the influence of city life have all proved in- jurious to health and morals. Connected with the foregoing are the personal factors: overcrowded, ill-ventilated and unsanitary homes; unclean personal habits; the periodical feasts and famine; and the living about, with its consequent parental irresponsibility and neglected childhood. Through plural marriages 64 are offered increased opportunities for the mating of the tuber- culous with the tuberculous and with the alcoholic and syphilitic, frequently all these conditions being found in one or both parents. The dissipation and unwholesome living of the youth, the fact that sixty to seventy per cent of the Winnebago harbor a specific infection , and the indolence and improvidence of many of the men, present a condition favor- able to the tendency toward and contraction of tuberculosis. The Winnebago are passing through a long trial which is to determine whether any remnant of the tribe shall sur- vive. Such survival will arise only from the presence of enough individuals in each generation who will keep them- selves free from the vices and practices which are certain to result in the extinction of many of their tribal families. Enough- young men and women must be found willing to adopt the advice of medical and sanitary science and live lives which will enable them to beget and rear children free from the taints which are destroying so many members of the tribe. The present health conditions on the reservation of this once important tribe of Indians become a matter of serious concern, for no portion of a population directly suffers un- less the remainder indirectly suffer with it. Tuberculosis is as great a menace to the white population as to the In- 63 Cf. Report of the Commissioner of Indian Affairs, 1846-47, 104. 64 Not polygamous marriages. Cf. footnote 65, p. 46. Tuberculosis Among the Winnebagv 45 dians themselves, for there are from two to three times as many white people living on the reservation as there are Indians. The Winnebago are beginning to move to the cities where they take up work in the packing houses. Thus far they are only trucking, but soon they will be handling foodstuffs. It seems wise to proceed energetically at once to pro- phylactic measures — to the introduction of activities tend- ing toward better health and better morals, and through this protection, which is really the inherent right of the Indian, to protect also the white population which comes directly or indirectly in contact with him. The health situ- ation is no longer an Indian problem, but a community problem — a public health responsibility. APPENDIX Family Distribution of Tuberculosis In the preceding pages we have discussed the incidence of tuberculosis among the Winnebago based upon the par- tial records covering a ten-year period. A second method of determining its occurrence was attempted by securing histories, as nearly complete as possible, of some of the fam- ilies in which cases were found. The group studied in- volves 110 individual families or over one-third the families on the reservation. Many complex relationships were encountered. The smallness of the group and the fact that there is no immi- gration and little intermarriage with outside persons, causes numerous unions between relatives. Of the 110 single families, 72 constitute a marriage tangle. More baffling still is the fact that many of the Winne- bago enter into marital relations with a great number of individuals. 65 Technically polygyny is not practiced except in rare instances, although the absence of legal control of domestic relations makes divorce and subsequent re- marriage a very easy procedure, and encourages unions so unstable as to amount, at times, to promiscuity. 68 Num- erous examples were found of three and four marriages, some of six, eight, or ten, while others are reported as "many husbands" or "many wives", the exact number not being clear in the memory of the relator. Thus the 110 single families 67 include 21 families with children of the half "The majority of these unions are marriage by tribal custom, which is simply the abandoment of the spouse and perhaps the im- mediate marriage by Indian custom of another, merely the selecting of a mate and living together by mutual consent. 66 Cf. footnote 54, p. 35. 67 By the single family is meant the primitive social unit — the marriage or pairing between one man and one woman, though the union be often transitory and the rule frequently violated. Cf. How- ard, History of Matrimonial Institutions, I, 89-110. Tuberculosis Among the Winnebago 47 blood ; 13 families in each of which there are children by the same father but of different mothers; and 8 families in each of which there are children of the same mother but of different fathers. Included also in the 110 families are 10 unions with no offspring. 68 A few illustrations showing the distribution of disease and the complexity and freedom of the marriage relations follow. In one case a man, recently deceased, infected with syphilis, has had six wives. The first wife is still living and is at present mated to her sixth husband. The second wife died of pulmonary tuberculosis and was also infected with syphilis ; the third wife gave birth to a boy who died of pulmonary tuberculosis at the age of twenty years ; and the fourth wife who had previously been married many times and given birth to many children, became with this husband the mother of two tuberculous children. She is now married to a man who was the father of two deceased tuberculous children by a former marriage. In a second case a tuberculous syphilitic, being also alco- holic and immoral, was married to two tuberculous women. The first wife now deceased, was also infected with syphilis. She gave birth to ten children, all dying in in- fancy. The present wife having had many husbands and given birth to several stillborn children became with one husband (family history free of tuberculosis) the parents of a child which is pretuberculous, requiring careful atten- tion. The union of this latter husband to an apparently healthy woman of another tribe (previously married and having borne four healthy children) has resulted in three healthy offspring. In another case a previously married, tuberculous woman was wedded to a twice previously married tuberculous man, one of his former wives and a child having died of tubercu- losis. Very shortly after the demise of the above third wife, the husband mated with a fourth spouse. 0S The writer is indebted to Professor George Elliott Howard for valuable assistance rendered in classifying family relationships. 48 Nebraska State Historical Society The family relationships of the group studied have been traced through from three to seven generations. Owing to the great frequency of marriage the line of descent is constantly broken. To the extent that it was possible to secure family histories, the line of descent is traced chiefly through the female, and whenever possible through the male line." These relationships are to be graphically re- presented in the form of pedigree charts depicting the family distribution of tuberculosis. Fifteen distinct trees are in the process of construction. These charts with eugenical analyses will appear in a later publication.