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wheezing in south Asian and white children: prevalence and clinical
significance. J Allergy Clin Immunol 2006;118:528–30.
34
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childhood: Retrospective and prospective assessment. Eur Respir J
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Chauliac ES, Silverman M, Zwahlen M, Strippoli M-PF, Brooke AM,
Kuehni CE. The therapy of pre-school wheeze: appropriate and fair?
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of ‘‘wheeze’’ and its impact on asthma estimates. Eur Respir J
2006;28:1124–30.
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definition in childhood wheezing illness: a data-driven approach.
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International Journal of Epidemiology 2007;36:985–987
doi:10.1093/ije/dym132
Celebration: William Farr (1807–1883)—
an appreciation on the 200th anniversary
of his birth
DE Lilienfeld
Accepted
22 March 2007
If one were to ask a student in an introductory epidemiology
course which Victorian epidemiologist most influenced the field’s
development, there’s a good chance the student would say ‘John
Snow’. As that student begins collecting surveillance data as part
of a doctoral thesis, the odds are good the student will not know
who first developed the concept of surveillance. When the student
begins analysing those data, there’s a likelihood the data will be
coded using the International Classification of Diseases (ICD),
especially if the data concern more than one disease entity.
Should the results indicate the need for public health action, the
student might contact a local, state or federal public health
agency to report the results and advocate for appropriate
intervention. Yet, in each of these instances, the influential
Victorian epidemiologist who pioneered in the area of the
student’s actions was William Farr (Figure 1).
Farr is relatively unappreciated by modern epidemiologists
compared with his more feted peer, John Snow.1–3 Yet, it was
Farr who developed the first national vital statistics system and
assured its use as a surveillance instrument. His efforts also
Stanford University School of Medicine, Palo Alto, California, USA.
E-mail: [email protected]
facilitated the use of that system for the conduct of
epidemiologic studies. Farr’s endeavours to craft a disease
nosology usable by vital statisticians and epidemiologists led to
the creation of the ICD.4 The structure of the ICD derives from
Farr’s 1860 proposal.4 These concepts and ideas have become
interwoven into the fabric of epidemiology, so much so that
Farr’s name is not necessarily mentioned as the innovator. Yet,
without his many contributions, the face of epidemiology today
would be markedly different.
A definitive biography of Farr and compilations of his
writings provide ample opportunity for modern epidemiologists
to learn about Farr.4–8 In view of his considerable contributions
to the discipline, it seems fitting to celebrate his 200th birthday
with brief considerations of both his biography and his impact
on our field.
Biography
William Farr (November 30, 1807 to April 14, 1883) was born
in Kenley, Shropshire, England to poor parents.9 When Farr
was 2 years old, he moved to Dorrington. In Dorrington, he
came under the influence of Joseph Pryce, the town’s squire
(http://en.wikipedia.org/wiki/William_Farr, accessed November
25, 2006).
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Published by Oxford University Press on behalf of the International Epidemiological Association
ß The Author 2007; all rights reserved.
986
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Educated at the local school, Farr decided in 1826 to study
medicine. He undertook studies in Shrewsbury; and he
supported himself as a dresser (surgeon’s assistant) in a
nearby infirmary, walking 14 miles daily. Three years later,
Farr inherited £500 from Pryce’s estate; he used these funds to
travel to France for continued medical studies, where he was
introduced to hygiene and medical statistics. The Paris School
was in its heyday; Pierre Louis was establishing a numerical
approach to clinical research. Farr is known to have attended
Pierre Louis’ classes, but Eyler suggests Farr’s interest in
medical statistics did not derive from Louis alone.4 Farr also
acquired some training in Switzerland.
In 1831. Farr returned to Shrewsbury for 6 months work as a
house surgeon, and then went to University College in London.4
A year later, the London Society of Apothecaries qualified him
as a physician, though some suggest he practised as a
pharmacist.9 In 1833, he married a farmer’s daughter and the
couple settled in London near Fitzroy Square. Farr wrote
articles on hygiene, public health and statistics (http://
www.lshtm.ac.uk/library/archives/farr.html, accessed November
25, 2006) to supplement his income. The quality of this work
commanded the attention of the editor of the Lancet,
Dr Thomas Wakley. In 1837, Farr completed two works of note:
a chapter called ‘Vital Statistics’ for the pre-eminent Victorian
economist John McCulloch’s reference text Statistical Account
of the British Empire, and an article on consumption (of which
his wife would die that same year) with Sir James Clarke.9,10
Clarke was so impressed by Farr that in 1837, when the Office
of the Registrar General began operations, he and Wakley
recommended Farr for the post of Compiler of Abstracts.
The Registrar General’s Office had been created by Parliament
in 1836 to track births and deaths in England and Wales as
the means of assuring the proper transfer of property rights
Contributions to epidemiology
Farr’s contributions to epidemiology are myriad. They range
from systems construction to the ‘Farr’s law of epidemics’
(the latter refers to Farr’s observation that the risk of cholera is
inversely related to altitude).4 In consideration of Farr’s efforts,
we must distinguish between what Farr knew in the 1800s and
what we know today. For example, Farr occupies a prominent
role in the epidemiologic investigations into the means by
which cholera spread. Yet his conviction that miasmas were the
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Figure 1 Dr William Farr. Courtesy of ‘Victorian Times Project’ based
at CDLR at the University of Strathclyde, and the ’Big Lottery Fund’
(formerly New Opportunities Fund). Reprinted with permission
between generations of the landed gentry (http://www.histpop.
org.uk/demo-b/servlet/View?path¼Browse/Essays&active¼yes&
mno¼2002, accessed November 25, 2006). Any activity beyond
such tracking exceeded Parliament’s intent. Hence, Farr’s
appointment as Compiler of Abstracts did not carry with it
responsibility for any of the vital statistics/epidemiology projects
Farr would take on during the next four decades (http://
www.arts.gla.ac.uk/History/Medicine/bdhiggs.doc,
accessed
November 25, 2006).
As Compiler of Abstracts, Farr created the first national vital
statistics system.4,11 He began the compilation of vital statistics
data on an annual basis, including analyses of causes of death
and assessments of mortality by occupation. To support this
work, he developed a nosology from which the ICD developed.
Farr was an enthusiast on the use of vital statistics, and his
efforts in this regard were recognized by the London Statistical
Society (predecessor of the Royal Statistical Society), which
elected him Treasurer, Vice President, and in 1871, President.
Farr’s advocacy of vital statistics found its way into several
activities outside the bounds of the Registrar General’s Office,
including data (and analyses) for Sir John Simon’s Local Board
of Health, the Royal Army and Navy and Dr John Snow’s
landmark epidemiologic studies on cholera. With regard to the
latter, Farr was not an early adopter of William Budd’s and
Snow’s hypothesis that contaminated water was the means by
which the epidemic propagated.12,13 Until he reviewed the data
for the 1853 epidemic of cholera in Newcastle, Farr contended
the spread of the disease was attributable to miasmas (14-14).
However, data from the Newcastle outbreak were sufficiently
compelling to Farr for him to change that view.1,4,14–16
Following the death of his wife in 1837, Farr moved to Stoke
Newington in 1841. He remarried a year later (http://
www.lshtm.ac.uk/library/archives/farr.html, accessed November
25, 2006). His second wife bore him eight children, and the
family moved to larger quarters as its needs expanded. His
second wife passed away in 1876. Farr was self-taught as a
mathematician and a linguist (fluent in French, German and
Italian). He maintained a strong friendship with Florence
Nightingale.4,10,17 When she indicated an interest in vital
statistics, he obliged her with data she subsequently published.
Although there is some suggestion she might have discretely
been Farr’s Victorian mistress, it is not clear that she and Farr
were indeed lovers.4,10
When Major Graham, the second Registrar General and the
principal one under whom Farr served, retired in 1879, Farr
made it known he wished to be Registrar General himself.
However, he did not receive the appointment, and in
consequence, he retired in 1880.4,9,10 Three years later, he died.
THE LEICESTER RESPIRATORY COHORTS
Conclusion
William Farr’s contributions to epidemiology were both broad
and deep. His creation of a vital statistics system, role in the
formation of the International Classification of Diseases, and
prominence in resolving the mode of communication of cholera
in Victorian England were each seminal to modern epidemiology. The same can be said for his development of the concept of
surveillance.22,23 Sir Isaac Newton famously observed, ‘If I have
seen further it is by standing on ye shoulders of Giants.’
(http://en/wikiquote.org/wiki/Isaac_Newton, accessed November
26, 2006). In epidemiology, it is upon William Farr’s shoulders,
among others, that we stand today. For this reason, on
November 30, 2007, epidemiologists around the world should
toast William Farr on the occasion of his 200th birthday.
References
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Chloroform, and the Science of Medicine. New York: Oxford University
Press, 2003.
2
Vandenbroucke JP, Eelkman Rooda HM, Beukers H. Who made John
Snow a hero? Am J Epidemiol 1991;133:967–73.
3
Eyler JM. The changing assessments of John Snow’s and William
Farr’s cholera studies. Soz Praventivmed 2001;46:225–32.
4
Eyler JM. Victorian Social Medicine. Baltimore: Johns Hopkins
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5
Susser M, Adelstein AM. An introduction to the work of William
Farr. Am J Epidemiol 1975;101:469–76.
6
Susser M, Adelstein A. Introduction. In: Humphreys NA (ed.).
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Vital statistics: memorial volume of selections from the reports and
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health. Bull World Health Organ 2000;78:86–87.
9
Dunn PM. Dr William Farr of Shropshire (1807–83). Arch Dis Child
2002;87:67–69.
10
Dupaquier M. William Farr. In: Heyde CC, Seneta E (eds). Statisticians
of the Centures. New York: Springer, 2001. pp. 163–66.
11
Hardy A. ‘Death is the cure of all diseases’: using the General Register
Office cause of death statistics for 1837–1920. Soc Hist Med
1994;7:472–92.
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Lilienfeld DE. The greening of epidemiology: sanitary physicians and
the London Epidemiological Society (1830–70). Bull Hist Med
1978;52:503–28.
13
Lilienfeld AM, Lilienfeld DE. Foundations of Epidemiology. 2nd edn.,
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14
Halliday S. Death and miasma in Victorian London: an obstinate
belief. Br Med J 2001;323:1469–71.
15
Richards T. Farr sighted. Br Med J 1983;286:1736–37.
16
Halliday S. William Farr: campaigning statistician. J Med Biogr
2000;8:220–27.
17
Cook GC, Webb AJ. William Farr’s influence on Florence Nightingale.
J Med Biogr 2001;9:122.
18
Bingham P, Verlander NQ, Cheal MJ. John Snow, William Farr and
the 1849 outbreak of cholera that affected London: a reworking of
the data highlights the importance of the water supply. Public Health
2004;118:387–94.
19
Higgs E. Life, Death and Statistics: civil Registration, Censuses and the
Work of the General Register Office, 1936–52. A Local Population Studies
Supplement. Hatfield, Hertfordshire, UK: University of Hertfordshire,
2004.
20
Singer RB. The first mortality follow-up study: the 1841 Report of
William Farr (physician) on the mortality of lunatics. J Insur Med
2001;33:209–98.
21
Gerstman BB. Comments regarding ‘On prognosis’ by William Farr
(1838), with reconstruction of his longitudinal analysis of smallpox
recovery and death rates. Soz Praventivmed 2003;48:285–89.
22
Syrucek L. History of epidemiologic surveillance – W. Farr 1807–83.
Cesk Epidemiol Mikrobiol Imunol 1972;21:321–24.
23
Langmuir AD. Wiiliam Farr: founder of modern concepts of
surveillance. Int J Epidemiol 1976;5:13–18.
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causal agent of the disease is known today to be wrong.1,14–16,18
Nonetheless, Farr based his view on epidemiologic data
available at that time (in the 1850s), and he was quick to
acknowledge his error when better data so indicated. The
incongruence of his ‘law of epidemics’ with the development of
the 1866 cholera outbreak in England led him to conclude that
miasmas could not be the etiological agent. He then advocated
strongly on behalf of better water supplies to prevent recurrence
of the epidemic.14–16
The creation of a national vital statistics system amenable to
epidemiologic exploitation is arguably Farr’s single greatest
achievement.11 It not only established a means of providing
data to epidemiologists, it also was an exemplar for other
countries seeking to create similar systems. Further, the system
provided data not only for the cholera investigations which
unfolded during the 1850s and 1860s but also for the first
systematic studies in occupational epidemiology by Greenhow
and for Seaton’s analyses of the efficacy of smallpox vaccination.4,12 The latter became the scientific basis for English public
health policy for more than a half century. As Higgs has noted,
Farr’s success did not stem from his efforts alone; the RegistrarGeneral, Major Graham, played a strong supporting role,
without which it is not clear Farr would have been as effective
as he was.19 Nonetheless, Farr implemented a system which
has functioned, albeit with revisions to accommodate advances
in medicine and changes in society, for one and a half
centuries.
Not all of Farr’s accomplishments derive from his work in the
Registrar General’s office. For example, Farr was engaged by
the London Statistical Society to undertake an analysis of the
mortality associated with the treatment of lunatics. Although
by modern standards, his analysis was not refined, it suggested
several changes in the care given to such patients (http://
www.mdx.ac.uk/www/study/3_11.htm, accessed November 25,
2006).20 Surely this analysis is one of the earlier ones in health
service research.
Farr’s focus on accurate analyses resulted in his contributions
to the formation of the ICD. Though there are considerable
limitations to any nosology, this one facilitated the analysis of
data (fostering rational health policy) and thereby propelled the
public’s health forward. Farr’s work distinguishing risks and
rates is also noteworthy.21
987