EPIDEMIOLOGY OF TUBERCULOSIS—PARR 485 
Far worse was the situation among the other belligerent countries of the 
Continent, but only fragmentary statistical data are available to show the 
frightful increases in some of these areas. The statistics of tuberculosis 
mortality in France during the war are defective because of the absence of facts 
for the invaded regions, where the situation was at its worst. The data for the 
uninvaded portion show a sharp increase, particularly in 1917 and 1918. In 
the latter year the recorded rate was about 20 percent higher than in 1914. The 
aceuracy of these statistics is doubtful, and the actual increase was probably 
larger. To some extent the same observation probably holds for Italy, but in 
that country even the recorded deaths from tuberculosis in 1918 were over 40 
percent in excess of the 1914 rate. 
A few examples will show the extremely bad conditions in Belgium and in 
eastern and southeastern Europe. In Brussels the death rate from tuberculosis 
doubled during the war, from 177 per 100,000 in 1914 to 390 in 1918. In Vienna 
the rate in the period 1915-18 was 20 percent higher than in 1911-14, and in 
the early postwar years it increased to 50 percent above the prewar rate. In 
Budapest the number of deaths from the disease in 1917 was nearly double 
that of 1913, and it was but little less in 1918. In Warsaw the rate in 1917 
was 840 per 100,000, as compared with 306 in 19138; in Cracow during the same 
period the rate increased from 487 to 908 per 100,000. In Belgrade the tubercu- 
losis death rate in 1918 reached the almost incredible figure of 1,400 per 100,000. 
Typical of the trend of tuberculosis in the neutral countries of Europe dur- 
ing the World War are the experiences of the Netherlands and Switzerland. 
In the former, the death rate from the disease rose steadily, until in 1918 it 
was nearly 50 percent above the 1914 figure. In Switzerland, where the trend 
was Sharply downward before the war, the rate continued to fall at first, but 
rose in the latter part of the war to a peak of 207 per 100,000 in 1917, or 6 
percent above the rate in 1914. 
In our own country the mortality from tuberculosis showed little change 
during the World War period as a whole, but even here there was a slight 
increase in the death rate during the period of our active participation in the 
war. Thus the death rate in the original Registration States declined from 
148.6 per 100,000 in 1914 to 148.8 in 1916, but then rose to 147.1 in 1917 and 
further to 151.0 in 1918. 
These increases come about through break-down in resistance to 
disease on the part of the host, to increase in opportunities for infec- 
tion, and to a decrease in or, indeed, collapse of facilities available 
for proper recognition, isolation, and treatment of disease. Spe- 
cifically some of the factors for tuberculosis are: 
1. The entrance of women into heavy and fatiguing industry. 
2. The return of the older age groups to active employment. 
3. The return to work of persons of either sex or any age physically 
unfit to work. 
4, Long hours of work often emotionally compensated for by long 
hours of strenuous or injudicious relaxation—“burning the candle at 
both ends.” 
5. Relocation in areas of intense war-industry activity resulting in 
congested living conditions without adequate sanitary facilities. 
