Monday, 4 November 2019

A Prescription for Change: Training a Doctor in Nineteenth and Twentieth-Century Ireland

In this blog post, Natalie Baldwin, a graduate of UCD's MA in History of Welfare & Medicine in Society, explores the realities of training as a medical professional, past and present.

Today, when we think of a medical doctor, it is easy to imagine an intelligent, respected, hard-working and well paid members of society who enjoys a high social status. It is therefore tempting to assume this has always been the case, that a career in medicine has always been both socially and financially rewarding. It may be surprising, then, to learn of the ups and downs medical students and their families have faced since the nineteenth century. 

A Case of History Repeating Itself  

The Fitzgerald family kept a small but considerable archive of artefacts and documents relating to members of the family reaching back to the 1840s. When these were donated to the Royal College of Physicians of Ireland Archives, they presented an incredibly exciting opportunity for an inherently curious person like myself to get stuck in. As I began to work through this archive, what struck me most about the Fitzgerald family was that so many of its members entered into a career in medicine. What seemed to start with Alexis and his brother James in the 1850s resulted in a medical dynasty that still survives today. Two members of the family stood out especially. Dr James Fitzgerald was born in or around 1838 in Tipperary. He moved to Dublin in the 1850s to study medicine, a move that was perhaps in part motivated by the fact that his older brother Alexis did the same thing a few years earlier. Two generations later, his grand-nephew Gerald entered UCD, the reincarnation of the Catholic University of Ireland which James had attended, to study medicine. Like his great-uncle James, he was following a path set by his older brothers and by now, his father, as medicine had firmly taken root as the Fitzgerald family business. James and Gerald went on to leave Ireland once they graduated. For James, it was to join the Navy while Gerald was offered the chance to further his education and career by leaving for England and Scotland. Sadly, these were not the only striking similarities between the pair as both died prematurely back home in Ireland in their thirties.

Thinking about James as representative of a doctor’s education and career in the nineteenth century and Gerald as representative of the twentieth century, we will take a look at how the education, career, and social standing of a doctor in Ireland changed or perhaps, stayed the same.

Status Update

'A poor apothecary in a cart being drawn by his servant are 
overtaken by a wealthy couple in a horse-drawn carriage 
with a seat at the back for their servant'. 
Credit: ​WellcomeCollection​. ​CC BY

The decade or so preceding James’s entry into medicine saw many attempts to professionalise the sector. In trying to move medicine away from being considered a trade to a profession, this naturally had a knock on effect towards the social standing of the doctor. Generally, and particularly before the middle of the nineteenth century, medicine had a tripartite structure and like most structures, was hierarchical in nature. At the top there was the physician, followed by the surgeon with the apothecarist sitting on the bottom rung of the ladder. The three enjoyed differing levels of social status. Alongside the orthodox or ​regular practitioners, were the unorthodox practitioners or "quacks". These included druggists, bonesetters or any member of the medical community that occupied the fringes of society. The medical marketplace was already overcrowded, especially in England, and having to compete for patients alongside unqualified "quacks" naturally created some anxiety for the trained practitioner. 

The Medical Act, 1858 attempted to alleviate some of these concerns. The Act tried to regulate the education and training of doctors and required all practicing members to sign the registry of the General Medical Council (GMC). While it differentiated between regular and irregular practitioners by only allowing fully trained and qualified ones to sign the register, the Act failed to prevent "quacks" from actually practicing. Members of the public were still unlikely to be able to discern between the two. The Act went some way towards professionalising medicine by trying to control entry and setting a standard of training. This meant that registered practitioners could distance themselves from tradespeople by charging for a service rather than a commodity. However, the Act was considered a failure for many orthodox members of the community as it still meant they had to jostle their way through a saturated market rife with "quacks".1

So what did all this mean for James and Gerald? Well for James, he started his studies just a few years before the 1858 Act came into effect. In fact, he graduated the following year. For students studying at this time, the terms of the Act specified that they would not be penalised and their training and education would be valid. Gerald did not begin his studies until 1930 but even so, the Medical Act of 1858 could have caused some worries of their own for him, even almost seventy years later. Unlike his great-uncle, Gerald began his medical career in post-independence Ireland. However, like his great-uncle’s experience, medical education was still under the influence of Britain and the control of the GMC. The Medical Act of 1858 threw up its own obstacles for the medical profession in the newly established Free State. For starters there was talk of setting up a separate medical register for the newly partitioned island. This created unease amongst the community with many highlighting the fact that Irish doctors relied on work in Britain and therefore needed to remain eligible to sign the general medical register upon graduation. Universities would suffer too if the numbers of medical students dropped as they relied heavily on their fees to keep the university as a whole afloat. Luckily for Gerald and those who studied in the few years before him, the issue was resolved in 1927 with the Medical Practitioners Act where it was agreed that Irish doctors could still sign the general medical register.

The Price of Education 

Despite the fact that medicine was clearly an economically precarious and overcrowded business, in nineteenth and twentieth-century Ireland, many students, or indeed their parents, were motivated to study medicine by the promise of social mobility and the chance to earn a place among the ranks of the middle classes.2

'A foppish medical student smoking a cigarette, 
tankard  is on top of his medical books;  
denoting cavalier attitude (1854)'. 
Credit: WellcomeCollection​. ​CC BY

Encouraging your child to attend a medical school was not without its financial sacrifices though. Factoring in the cost of lodgings, lectures, grinds, clothing expenses, reading materials and general maintenance costs, it is estimated that sending a student to Cecilia Street where James received his education, cost about £400-500.3 Bursaries were available for less well-off students attending Cecilia Street who wanted to study medicine but amounted to only £40 a year for up to two year’s study. In most cases, the cost of funding a medical student’s education fell to the parents. Nothing in James Fitzgerald’s personal notes indicated he was working to fund his studies so most likely he was put through university by his parents. James’s older brother Alexis was also a doctor and graduated four years before he did. Considering a doctor during the late nineteenth century would go on to earn about £90 to £120 a year, it seems less likely that parents were driven by the financial incentive of having a doctor in the family. We should also remember that the sacrifices began well before sending a student to university as in the second half of the nineteenth century receiving just a second level education placed you in the minority.4 For James’s grand-nephew Gerald, the financial costs of a medical degree had increased further. Gerald graduated from UCD in 1936. In the years before the outbreak of World War Two, the cost of obtaining a medical education was said to be approximately £1500.5

The financial situation may not have improved for James even after he qualified and secured a position as assistant surgeon in the Royal Navy. For starters, navy surgeons had to acquire their own kit of surgical tools. This seems unreasonable enough but when you consider that an assistant surgeon like James was paid only about £2-£3 per month,6 the economic incentive for becoming a doctor seems less and less appealing.

Upwardly Mobile

If the potential financial rewards were not especially inspiring, it would seem more convincing that the motivation for parents to encourage their children into a career in medicine was driven by the sense of respectability garnered through having a doctor in the family. Kelly likens this to the social standing Catholic families in the late nineteenth and early twentieth century attained from having a priest in the family.7 James and Alexis’s parents must surely have enjoyed a significant sense of respectability as not only did they have two doctors in the family, but a priest as well in their third son Fr Michael.

There may have been other factors though in motivating James’s and Gerald’s entry into the world of medicine. Kelly writes about how medical education in Ireland tied in with notions of manhood and its transformative power of turning boys into men. She also speaks of how its competitive nature further emphasised the traditionally masculine nature of the medical student.8 As James’s older brother Alexis studied medicine too, it is possible to imagine that this competitive manliness tied in with sibling rivalry and he simply wanted to copy his older brother’s example.

The Family Business

By the time Gerald decided to begin his journey towards being a doctor though, things had changed quite a bit for the Fitzgerald family. While the two generations prior had seen his great-uncles James and Alexis carve a path into medicine, Gerald was born into quite a different landscape. Gerald’s father Alexis was doctor and medical officer at Waterford District Asylum at the time of Gerald’s birth in 1913. Many students entered into medicine because it was the profession of their father. Over 11% of students who graduated from the Queen’s Colleges in 1872-1917 had a family background in medicine.9 However, it wasn’t just Gerald’s father that could have influenced his decision. Not only were his father’s two uncles doctors, but his own uncle James as well as his two older brothers Oliver and Patrick. So while James and Alexis in the mid-nineteenth century may have been driven by a desire for middle-class respectability, Gerald may likely have felt that medicine was the family profession. 

The Spectre of Emigration 

Leaving Ireland upon graduating medical school was a fate that befell both James and Gerald. Ireland saw high levels of emigration generally throughout the late nineteenth and early twentieth century. This was particularly acute though within the medical profession.10 With so many doctors emigrating to England from the medical schools in both Ireland and Scotland, these years ushered in a period of underemployment among doctors. Add an abundance of qualified doctors to the fact that there still remained some competition from the unregulated practitioners, and there was now increased pressure to find suitable and fulfilling positions for the medical graduate.11

Out at Sea

'Naval officers and men on a ship, dressed in the 
uniform of nine labelled ranks of the Royal Navy'.
Credit: Wellcome Collection. CC BY  
James graduated in 1859. In a cohort of medical students studied by Jones from the period 1860-1960, the number working outside of Ireland ten years after graduation was found to be 41%. James was therefore not unusual in his path following graduation as the same cohort studied showed that for those not practicing in Ireland after graduation, the majority either set up their own practice in England or, like James, served in the military or within the British Empire.12 It may seem unusual for a Catholic like James to have joined the Royal Navy but in fact, he was one of a growing number of men from Ireland who joined from the 1840s onwards. For them, life in the Navy particularly as a medic, offered an escape from Ireland and a chance to further their career in a way that staying at home couldn’t allow.13 So while it would seem that he may not have been well rewarded financially, perhaps the adventure was enough to keep him there for seven full years considering many assistant surgeons left after serving only three years.14 Although, considering his sick list seemed to mainly record him treating case after case of venereal disease and coughs and colds, life in the Navy undoubtedly wasn’t one non-stop adventure.

The Export Market

Ireland enjoyed a good reputation in the post-independence era for its medical schools but like students of James’s era, emigration was still prevalent for graduates owing somewhat to economic hardship in the post-war period.15 The hundred year period from 1860 to 1960, which included Gerald’s years of study, saw more students go through Irish medical schools than there were positions for at the other end. Essentially, the emigration of medical graduates was considered par for the course. It may therefore seem strange that universities in Ireland continued to oversubscribe students for their medical schools knowing full well that they would be exporting many but the universities, particularly the Catholic University, relied heavily on the contribution medical students’ fees made towards the running of the entire institution.16 Gerald moved to London in 1938, two years after he graduated from UCD. He had been awarded a travelling scholarship by the Mater Hospital to study neurology. He stayed in London for some time before eventually moving to Edinburgh to further his career again, this time to study psychiatry. He did not return to Ireland until about 1945 when he took up a post in the Mater Hospital.17 Like James, leaving Ireland had certainly afforded Gerald greater opportunities to develop as a doctor, gain independence, and broaden his skills.

The More Things Change…

What of today then? We could easily assume that a doctor in the twenty-first century has it much easier than James or even Gerald did. But perhaps things actually are not so different. While a doctor’s social status may have improved since James’s time, recent studies have shown that members of the medical profession report feeling under-respected. With increased competition from other healthcare practitioners echoing the struggle of the previous generations, and less and less professional autonomy, many doctors feel they do not enjoy the same level of status as the profession once did or as perhaps they expected to experience.18 There are regular reports in the news highlighting the fact that Ireland continues to produce doctors for export with many leaving for the UK, Australia and the US. Staff shortages are common place in Irish hospitals along with overcrowding from patients. Salaries for consultancy positions have not recovered to the levels they were before the economic recession.19 

So if today’s doctor is overworked, underpaid, and under-respected, who would want to join such a profession? Well apparently, quite a lot of people. Places to study medicine in Irish universities are still some of the most competitive, typically requiring some of the highest CAO points. The introduction of the Health Professions Admissions Test (HPAT) some years ago attempted to ensure that well rounded candidates were offered places rather than just those that achieved the highest academic scores. School leavers and even mature students are clearly not deterred despite the various challenges – new and old – that beset the medical profession. Like James and Gerald, many could be following an already established family path into the profession. It is likely that for many, having to leave Ireland upon graduating is seen as an exciting opportunity rather than enforced emigration. Rather than being seen as a badge of social standing, there is also the possibility that an offer to study medicine is viewed as a mark of intellectual status. It is well known how hard a secondary school student must work to earn enough Leaving Certificate points to be offered a place. To actually complete the five to six years of medical training is definitely a remarkable achievement. For some, perhaps medicine is just in the blood; a path they were destined to follow, neither a trade nor a profession but simply a vocation.

Natalie Baldwin

Natalie Baldwin completed her MA on History of Welfare & Medicine in Society at the UCD Centre for the History of Medicine in Ireland in 2018/2019.


Research completed in collaboration with Harriet Wheelock, Keeper of Collections, Royal College of Physicians of Ireland Archive Collections.

1. Anne Digby, ​Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720-1911 (Cambridge, 2002), pp 28, 31, 36-37.
2. Laura Kelly, ​Irish Medical Education and Student Culture, c. 1850-1950 (Liverpool, 2017), pp 200-203, 71, 73.
3. F.O.C. Meenan, ​Cecilia Street: The Catholic University School of Medicine 1855-1931 (Dublin, 1987), p. 24.
4. Kelly, ​Irish Medical Education, p. 74.
5. ‘​The Cost of Medical Education’, British Medical Journal, 6 September 1947, p. 392.
6. Jonathan Charles Goddard, ‘The Navy Surgeon’s Chest: Surgical Instruments of the Royal Navy during the Napoleonic War’, ​Journal of the Royal Society of Medicine, 97 (2004), pp 191-197.
7. Kelly, ​Irish Medical Education, p. 84.
8. Laura Kelly, ‘Irish Medical Student Culture and the Performance of Masculinity, c. 1850-1930’, ​History of Education, 46, no. 1 (2017) pp 39-57.
9. Kelly, ​Irish Medical Education, p. 73.
10. Greta Jones, ‘“Strike Out Boldly for the Prizes that are Available to You”: Medical Emigration from Ireland 1860-1905’, ​Medical History, 54 (2010), pp 55-74.
11. Digby, ​Making a Medical Living, p. 140.
12. Jones, “Strike out Boldly,’’ pp 56, 59.
13. S. Karly Kehoe, ‘Accessing Empire: Irish Surgeons and the Royal Navy, 1840-1880’, ​Social History of Medicine ​ 26, no. 2 (2012), pp 204-224, 207.
14. ‘Army and Navy Medical Service’, ​British Medical Journal 1, no. 275 (1866), p. 366.
15. Kelly, ​Irish Medical Education, p. 201.
16. Jones, ‘Strike out Boldly’, p. 68.
17. Edward A. Martin, ​A Historical, Biographical and Anecdotal Account of the Neurological Sciences in Ireland from the earliest days to 1975 (Dublin, 2012), pp 40-1.
18. Lipworth et al. Doctors on Status and respect: A Qualitative Study, ​Bioethical Inquiry, ​10 (2013) pp 205-206.
19. ​Irish Times, 26 Dec 2017; Irish Times, 26 Sept 2018.