“Strike out Boldly for the Prizes that are Available to You”: Medical Emigration from Ireland 1860–1905

Throughout the late nineteenth and twentieth century there was a continuous flow of doctors emigrating from Ireland.¹ Governments and medical schools in Ireland were aware of this phenomenon, but most calculations of the extent of medical emigration were largely impressionistic. The Report of the Commission on Higher Education in the Republic of Ireland in 1967 commented:

Medical school authorities informed us that it was particularly difficult to place a figure on the rate of emigration of Irish doctors. A survey of the pattern of emigration over a long period involving the tracing of many individuals would be required to obtain accurate information and, in particular, to isolate the number of doctors who emigrate permanently. This we have not had the opportunity of doing.²

In order to gain a more accurate insight, the current study surveyed doctor emigration from Ireland between 1860 and 1960. The cohorts were selected from five leading medical schools in Ireland.³ Beginning in 1860, the survey looked at the cohorts at five-year intervals until 1960. It thus covered 4,265 graduates, who were examined for their place of residence in the Medical Register and the Medical Directory ten years after graduation. Smaller studies were done five, fifteen and twenty years after graduation to establish the accuracy of the ten-year cut off point. The figures obtained suggest that for the period 1860–1960 about 41 per cent of the cohorts examined were practising outside Ireland after ten years, around 44 per cent were in Ireland, and 15 per cent were unaccounted for.

However, broken down by period, patterns of emigration change. Over the hundred years examined, medical emigration, whilst still a significant part of Irish experience, drops. Other changes occur in terms of destination and motivation. This article, therefore, concentrates upon the nature of medical emigration between 1860 and 1905 using the 1905 graduates as the last cohort. This was done because the following cohort of 1910 started their careers in medicine around the time of the National Insurance Act of 1911 and, shortly after, the 1914–18 war. These two events significantly changed the situation for the emigrant doctor and suggest that the cohorts of 1910 and 1915 need separate treatment.⁴

The five major medical schools whose cohorts were studied were the Queen's Colleges of Galway, Cork and Belfast founded in 1845, the University of Dublin (Trinity College, TCD) and the Royal College of Surgeons in Ireland (RCSI).⁵ These, together with the Apothecaries' Hall, Dublin, whose graduation lists were not available at the time of writing, were the main licensing schools in Ireland in the late nineteenth century. The Royal College of Physicians of Ireland produced licentiates (LRCPI).⁶ However, it was an examining body only, traditionally associated with the School of Physic in Trinity College, Dublin. It opened its examinations to the students of the Catholic Medical School (1854) helping to ensure that school's survival. Until the Medical Act of 1886 the standard degree in the graduation lists was MD. After 1886 it became the “holy trinity” of MB, BCh, BAO (medicine, surgery and obstetrics). The Royal College of Surgeons educated students and licensed them (LRCSI). After the Medical Act of 1886 created a conjoint examining board with the King and Queen's College of Physicians of Ireland, the graduates of the RCS were both LRCSI and, until 1889, LKQCP. By 1900 the Irish degrees recognized by the General Medical Council (GMC) were LAH, MB, BCh, BAO, LRCSI and LRCPI.

Medical school and licensing body were not always the same. The Catholic Medical School in 1865 had 20 first year students of whom 17 graduated from the Royal College of Surgeons (LRCSI), two from the Apothecaries’ Hall, Dublin (LAH), and one via the exams of the King and Queen's College of Physicians of Ireland (LKQCP).⁷ The major private schools—Steevens, Ledwich and Carmichael—in the same year had a total between them of 56 registered students, of whom 26 eventually took their exams at the Royal College of Surgeons, 6 at the School of Physic (Trinity College's medical school), one at the Queen's College, Belfast, and 20 at the Apothecaries’ Hall.⁸ The students of the Catholic Medical School continued to graduate LRCSI and LRCPI, although after the Catholic school became the medical school of University College, Dublin, in 1909 this changed.⁹

The graduation lists of these five schools provide, therefore, a pretty comprehensive picture of the outcome of medical education in Ireland in this period. They include a small proportion who were already licensed to practise largely via the Apothecaries’ Hall or who, particularly after the medical reforms of the 1880s, attempted to upgrade their original qualifications, but the majority were newly minted graduates.

There are, of course, complexities in the picture of emigration presented in Table 1. By excluding medical students, it underestimates the amount of actual emigration. It was still common in the late nineteenth century for Irishmen to seek an education outside Ireland particularly in Scottish universities; more rarely in provincial English schools, London, Oxford or Cambridge. Anne Crowther and Marguerite Dupree's work on the cohort of graduates from the medical schools of Edinburgh and Glasgow suggests that 6 per cent of those who began the study of medicine in Glasgow in 1871 and 4 per cent in Edinburgh were Irish born. This was about the same for Welsh students but considerably less than the proportion of English students—12 per cent in Glasgow and 32 per cent in Edinburgh.¹⁰ However, only a small proportion of Irish graduates returned to Ireland.¹¹ Crowther and Dupree state that 56 of their cohort were born in Ireland but only 12 practised there.¹²

Table 1.

Destination of medical graduates from Ireland. Percentages. Raw numbers in brackets

Years	Ireland	Not in Medical Register	Outside Ireland
1860−95	32% (244)	15% (112)	53% (398)	754
1900−15	37% (228)	14% (85)	49% (305)	618
1920−40	47% (660)	14% (200)	39% (540)	1400
1945−60	51% (750)	16% (235)	33% (489)	1474
Total 1860−1960	44% (1882)	15% (632)	41% (1732)	4246

Source: Medical Register of the United Kingdom, for the relevant years.

Similarly Laura Kelly's work examines the destinations of Irish graduates trained in Glasgow University medical school between 1859 and 1900 five years after graduating. Her conclusion is that only one in three of the Irish-born medical graduates of Glasgow returned to practise in Ireland. Some whom she records as returning to Ireland within five years, may subsequently have joined the Irish doctors migrating within the ten year time span used in this study. But these would be untraceable by the criteria used here, which examines only graduates from Irish medical schools.¹³ So this study, by excluding Irish men and women graduating from Scottish medical schools, underestimates the total amount of medical migration from Ireland. Additionally, figures for the “not ins” (meaning those whose names do not appear in the relevant Medical Register) remained remarkably consistent over time. But it cannot be assumed that some of these were not in fact practising overseas in regions where being on the British Medical Register was deemed irrelevant. However, in the majority of cases, death or change of profession accounts for most of those dropping off the register.

The bare figures from this study also underestimate the amount of peregrination that took place in the medical profession in the late nineteenth century. Settling down five or even ten years after graduation was not possible for every medical graduate. Some served several years as ship's doctors on the Cunard or Pacific and Orient (P and O) shipping lines prior to setting up practice. Those who settled in Ireland or migrated to Britain often moved several times as assistants in practices before becoming established in a particular location. Though most were settled after ten years, this outcome cannot always be assumed.

An example of a highly mobile doctor is Archibald Montford, born in Carlow, who entered TCD medical school aged eighteen and graduated in 1875 with a silver medal for clinical medicine.¹⁴ Montford, after attending the Rotunda for clinical training, studied at Bonn and Vienna. In the late 1870s he appears in Staffordshire at Brindley Ford as surgeon to the Coal and Iron Foundry at Biddulph and doctor to the Manchester Assurance Society. During 1881–2 he is in Kent, and in 1883–5 he is ship's surgeon on the SS Kepler. Thereafter his address is “un-communicated” until he reappears back in Ireland at Tiny Park, Carlow, in 1890. By 1900 Montford has a Dublin address where he is still residing in 1910. But thereafter his address is again “un-communicated” until he finally drops out from the 1918 Medical Directory. Such a restless career is, however, unusual, and from supplementary studies done of longer periods, the ten year cut off on the whole provides a reasonable measure of eventual settlement.¹⁵

None the less, some graduates who after ten years are registered outside Ireland were in military or colonial service and eventually moved back. This can be seen by wills probated in Ireland from Irish addresses by doctors who spent their careers in India or other parts of the British empire, and by entries in D G Crawford's Roll of the Indian Medical Service on place of death. The probated wills in Ireland include that of Robert Reid, who graduated in 1854 from the Queen's University of Ireland, obtaining the licentiateship of the King and Queen's College of Physicians in 1865. He spent twenty-five years as a surgeon in the Bengal army and died in Ireland at Lisburn, County Antrim, on 26 March 1907. Reid drops out of the Medical Directory after 1893 and does not appear to have practised in Ireland. In Reid's case this may have been because of the significant fortune he had amassed. In addition to his RAMC pension, he left £21,017, much of it in securities, bonds and deposits in the Hong Kong and Shanghai Bank, and in Grindley's Bank.

For others in the military or colonial service, retirement might mean re-establishing themselves in private practice. Robert Taafe was born in 1851 and graduated in 1875 from TCD's medical school. Taafe joined the Indian Medical Service (IMS) in 1876 and spent ten years, including active service, on the North-West Frontier. On a ten-year analysis he slips into the category of outside Ireland. However, Taafe is recorded in Crawford as taking up medical practice in Kingstown, County Dublin, after his resignation from the IMS.

Thus there are all kinds of factors which make this sort of study an inexact science. The career of each individual is unique. However the period 1860–1905 produces a cohort of around 976, the majority of whom show relatively settled patterns of career progression. Two destinations in particular, a practice in England or service in the military or the colonies, stand out as the route taken by the majority of graduates practising outside Ireland. To sum up, around 53 per cent were practising outside Ireland after ten years.¹⁶ The majority were in England.¹⁷ Another substantial number served in the military or the colonies of the British empire, and emigrant destinations such as Australasia. A minority went elsewhere—China and the Far East, South America or Europe—but they often worked for British firms or for British communities and thus remained within the British sphere of influence.¹⁸

Crowther and Dupree's study shows even higher rates of dispersal. Ten years after graduation, 38 per cent of medical graduates from the two Scottish universities of Glasgow and Edinburgh were practising in Scotland, and around 60 per cent outside Scotland, mainly in other parts of the British Isles, particularly England. But their figures of migrants are boosted by the fact that Edinburgh recruited students much more widely from the British Isles, and many of her students, rather than emigrating, returned to their place of birth after their studies were completed.¹⁹ If we take Glasgow alone, where the proportion of Scottish born students was higher than Edinburgh, 48.9 per cent of Glasgow's medical graduates remained in Scotland and around 54 per cent migrated, comparable to figures of Irish medical emigration overall in this period. Trinity College, Dublin, enjoyed the prestige of an old established school, but only rarely were her medical students drawn from outside Ireland.²⁰ For other Irish medical schools the number of non-native students was even less. By the end of the nineteenth century these schools were recruiting predominantly from within Ireland and even from the surrounding locality.²¹

The majority of medical emigrants, as shown in Table 2, ended up in practice in England and exhibit a settled life conforming to the common experience of the average general practitioner of the time. Charles Emilius Ross graduated from the Royal College of Surgeons in 1875 and by 1885 was practising in Worcester where he remained for the remainder of his professional life. He worked as a surgeon at St Mary's Cottage Hospital and at Tenbury Dispensary. To these duties he added those of district medical officer of Tenbury Union and surgeon to the Odd Fellows and Foresters Assurance Company. He was still at Tenbury in 1904. His career paralleled ones in Ireland such as that of William James Browne. Browne graduated the same year as Ross also from the RCS via the private Ledwich Medical School and Mercer's Hospital. He worked at the Coombe Hospital, Dublin, and eventually settled in Church Hill, Letterkenny, Donegal, where he was medical officer for the Dispensary, district medical officer attending the Royal Irish Constabulary and resident surgeon to the Londonderry County infirmary and City Fever Hospital. These two individuals represent the majority who eventually achieved the desired objective of a practice plus public emoluments and relatively settled professional status.

Table 2.

Destinations of the 976 graduates examined 1860−1905 ten years after graduation

Ireland	England Wales and Scotland	Navy and army	Africa	India	Australia and New Zealand	North America	Other, including West Indies	Not In	Total
316	277	137	29	45	27	2	13	130	976
32.3%	28.3%	14%	2.9%	4.6%	2.7%	0.02%	1.3%	13.3%

Medical Incomes

One frequently quoted cause of emigration was the poverty of Irish doctors in comparison with their counterparts elsewhere in the United Kingdom. A picture of the poverty-stricken Irish Poor Law doctor has come to dominate the historiography of the Irish medical profession. However, comparisons between the financial situation of Irish and English practitioners show a more complex situation. Anne Digby's book on the medical profession in the late nineteenth and early twentieth century has examined the income of general practitioners in England in 1877, 1899 and 1909.²² According to their gross annual income, Digby divides general practices into four categories. These are: “small”, those which provided an average income of between £300 and £399 per annum; “standard”, those yielding between £400–£599 and £600–£799 annually; “good”, those producing an annual income of £800 to £999; and “first class”, those yielding £1,000 to £1,499, together with a small number worth over £1,500. She suggests that, in 1877, three fifths of country practices in England were “standard practices” and a remaining fifth divided between small and first class. Urban practices, on the whole, provided greater opportunities for average higher incomes. Professional overcrowding in the 1890s led to an increase in the number of small practices but, by 1909, the figures had returned to the 1877 configuration. Digby attributes the recovery of income in that period to the decline in overcrowding in the profession produced by a drop in the number of recruits to medical schools in the 1890s.²³

Among the sources she used was the Report of the Committee to inquire into the causes which tend to prevent sufficient eligible candidates from coming forward to the Army Medical Department, 1878–1879. This examined the level of remuneration for medical officers in the armed services in comparison with the opportunities available to medical graduates outside.²⁴ Digby quotes from this to the effect that a new graduate might expect to obtain an income of £300 per annum “within 5 years of commencing practice”, which would rise to £500 within 10 years and peak at around £800–£1,000—standard to good—towards the end of a career.²⁵

The report also covered Ireland and replies about medical incomes in Ireland were received from the medical schools at Queen's College, Belfast, and, in Dublin, the Carmichael Medical School, Dr Steevens’ Medical School and the Catholic Medical School. None of the advice suggested significant differences between Ireland and England and Wales. The Carmichael Medical School believed, with a few exceptions, that the usual course for a graduate in Ireland was to seek a dispensary medical officer's post. The rate of pay was £90 to £140 per annum plus fees for acting as registrar of births and deaths, and for vaccination—a further £30 to £50 per annum. To this a part-time appointment as medical officer of health at £10 to £20 per annum was usually added. So the entire fixed income for a newly graduated doctor in Ireland was £120 to £220 per annum. According to the representative of the Carmichael School, “The private practice it would of course be impossible to gauge but it may be stated that there is hardly any district in Ireland where it would not be worth at least £150 a year.”²⁶ This gave an average starting salary for doctors of £270 to £370, comparable to that in Britain. This might be even higher if one of the more lucrative public appointments was secured. As the Carmichael School representative commented, “The County infirmaries and lunatic asylums are more valuable but they are obtained with more difficulty.”²⁷

The consensus among the Irish medical schools as a whole was that a medical graduate could expect an income of £280 to £360 (small by Digby's calculations) at the start of his career. Ten years later he would earn a standard to good income—£800 to £1,000 according to Dr Steevens’ Medical School, and £500 according to the medical school of Queen's College, Belfast. Twenty years into a career this would rise to a standard income of £700, according to the Queen's College medical school in Belfast, a figure surpassed by Dr Steevens’ Medical School's calculation of £800 to £1,000 (good) after ten years. The trajectory of a medical graduate's career in Ireland, therefore, was not unlike that of his English counterpart. Starting modestly, the expectation was that, after ten years, income would rise to the standard level and in some cases even reach the “good”. In fact the general tenor was positive. The representative of the medical school of the Catholic University joyfully recounted, “I am frequently astonished at the incomes former pupils enjoy and at the substantial proofs of material prosperity that families and homes present.” This included a student who, after ten years, was earning £900.²⁸ Medical schools might be expected to put the most favourable gloss on the rewards of medical practice in Ireland because, as will be outlined in the course of this article, they had a vested interest in encouraging recruitment. To put flesh on the bones of the situation, therefore, a more detailed examination has been made of the incomes of doctors in the region of Ballinasloe whose medical practitioners have been examined in 1875 and in 1895.²⁹

Medical Practitioners in Ballinasloe

Ballinasloe is a country town situated in County Galway in the largely rural, western province of Connaught. Its population in 1871 was 5,052. In the census of 1891 it had declined to 4,642.³⁰ The total population served by its medical practitioners would, of course, be larger, including villages and rural areas in the surrounding districts. Ballinasloe was relatively prosperous, though rural poverty could be found in the hinterland. Both the Irish Medical Directory and the British Medical Directory contain a list of doctors for the town of Ballinasloe for 1875 and 1895. The two lists are not identical.³¹ However, in 1875, in both lists there is a core of six doctors recorded as practising in Ballinasloe. By 1895 this has risen to eight active medical practitioners.³²

In 1875 Robert V Fletcher took over from R Eaton as the medical superintendent of Ballinasloe lunatic asylum. This was the most lucrative public appointment in the district, and Fletcher went on to enjoy a long career in this position. His salary for 1875 was estimated at £450 per annum, plus £145 in allowances, giving him a “standard” income of £595 from a public appointment. Fletcher, a graduate of Edinburgh in 1865 and the Royal College of Surgeons in Ireland in 1869, had been, before taking up the appointment at Ballinasloe, assistant resident physician at Downpatrick and then at Waterford Asylum. Twenty years later in 1895, Fletcher was still at the Ballinasloe Asylum but his salary had risen to £650, plus £150 allowances, qualifying by Digby's criteria as a good income.³³

The lunatic asylum provided remuneration for the medical fraternity of Ballinasloe in general. In 1875, Dominick Burke was visiting and consulting physician there at a salary, on 31 December 1873, of £125 per annum. He was also the medical officer of the Ballinasloe Workhouse from which he earned £120. To this he added a further £18 as consulting sanitary officer, £15 for various duties as medical officer of health, and £18 for work as executive sanitary officer. This was a total of £296 from the public purse alone. In 1895 James J Delahunt, who had graduated in 1879, succeeded him as consulting physician at the lunatic asylum. His salary was £120 per annum with none, apparently, of the accumulated additions which Dr Burke had secured in 1875. But Dr Delahunt also added dispensary work at £120 per annum, plus £14 for vaccination. This made a total of £254 for Delahunt from public appointments.³⁴ Dr Michael Comerford (graduated 1862) and Dr Eaton (graduated 1855 and 1856) also held positions at the asylum probably for ad hoc consultations for neither are down in the Irish Medical Directory as receiving regular salaries. But Dr Rutherford in 1875 got £50 per year as apothecary for the inmates, a sum which had risen to £125 in 1895.

The dispensary work in 1875 was looked after by Dr Patrick Horne. Ballinasloe Dispensary was one of six in the Ballinasloe Union and Dr Horne earned £120 for this, plus £6 6s. for vaccination. This was the highest paid and most populous dispensary district in the Union. Dr Thomas Kearns in Ahascragh earned £50 and Dr E P Sharkey, who graduated in 1833 and retired in 1885 due to “old age”, got £100 in 1875 for work in the Creagh Dispensary.³⁵ In 1891, according to the annual report of the Local Government Board for Ireland, the six dispensary districts of Ballinasloe between them had an average salary of £121, ranging from £118 to £143 10s.³⁶

A 1903 book published to help medical practitioners deal with their financial accounting listed three examples of typical income upon which the author based model tax returns. These, ranging between £435 and £710, may be taken as a reasonable guide to the accepted level of medical incomes. From the study of Ballinasloe doctors, incomes in this range were within reach of all of them.³⁷ But this would have been on the important assumption that, as the Irish medical schools maintained in 1878–9, a minimum of £150 per year through private practice was available. It is here that the financial strains on Irish doctors appeared.

Income of Irish Poor Law Officers

Sir Thomas Lough MP, in a speech to the Irish Medical Schools’ and Graduates’ Association in 1905, made reference to the on-going dispute on the remuneration of Irish Poor Law officials. According to Sir Thomas, “Fifty years ago their salaries had been fixed (as they were in England) on the supposition of private practice. This was an erroneous comparison to make now for, while the private practice still remained in England, it had departed, with a great many other good things, from Ireland.”³⁸ Private practice had not departed from Ireland. In fact, the disposable income of Irish families was increasing in this period and some of it found its way into doctors’ fees. There were towns in Ireland with a rising population in which a good medical living could be made. In 1875 Bangor, a prosperous seaside town within commuting distance of Belfast, had four doctors; this number had risen to twelve in 1908 to meet an almost threefold increase in population.³⁹ None the less, the situation with regard to private practice was not uniform throughout Ireland and, in certain areas, it was being squeezed by the falling population. This meant diminishing prospects for private practice. Thus in seven country towns with rural hinterlands, though the number of doctors shrank from 39 to 32 between 1875 and 1908, the proportion of medical practitioners to the total population of the towns increased from 1 to 843 in 1875, to 1 per 835 in 1908.

Table 3.

Ratio of doctors to population in towns decreasing in size

Place	Pop. 1871	No. of doctors 1875	Ratio of pop. per doctor	Pop. 1911	No. of doctors 1908	Ratio of pop. per doctor
Charlville, Co. Cork	2,482	6	413.6	1,925	4	481
Thurles, Co. Tipperary	5,008	5	1001.6	4,549	7	649.8
Dungarvan, Co. Waterford	6,520	5	1304	4,977	3	1659
Ballina, Co. Mayo	5,843	4	1460.7	4,662	5	932.4
Westport, Co. Mayo	4,417	5	883.4	3,674	4	918
Ennis, Co. Clare	6,503	10	650	5,472	8	684
Fethard, Co. Tipperary	2,106	4	526.5	1,473	1	1473
Total	32,879	39	843	26,732	32	835

Source: W E Vaughan and A J Fitzpatrick (eds), Irish historical statistics: population, 1821–1971, Dublin, Royal Irish Academy, 1978, and the Irish Medical Register.

In Ireland population decline meant that the magic words for those seeking a practice expressed in an exchange of letters in B W Lara's correspondence book dealing with the sale of practices in 1881, “the population is large and increasing” applied only to certain regions.⁴⁰ In addition, the use of the dispensary system, not just by the very poorest but by a large proportion of the non-pauper population, was considered by the Irish medical profession to aggravate the problem of private practice.⁴¹ According to one disaffected Irish doctor, “The dispensary medical officers have been and are compelled to attend on tickets numbers of persons who have no claim whatever to gratuitous attendance.”⁴²

The problem particularly affected the rural practitioner. The more straitened circumstances of rural practitioners, arising from a combination of fewer opportunities for private practice and the greater costs of travel, have been noted by Digby for England. They were more “economically precarious” and such a situation must have been replicated to a much greater extent in Ireland.⁴³ Cases of extreme penury were often cited in support of the Irish doctors’ 1903–5 campaign to improve the pay of Poor Law medical officers. Drumconrath, the rural dispensary district of one west of Ireland doctor, was described as a place which in former times was fairly populous:

But owing to the depression in agriculture of the last quarter of a century, cultivation has practically ceased, and the land is used for grazing only. As a result the labouring population has greatly decreased, a few herdsmen sufficing for large tracts; and whereas in 1851, when the dispensary districts were formed, the total population was some 27,000, it is now barely half that …

The story of the late medical officer of Drumconrath is one of the saddest among many such in the Irish Poor-law service. When he was appointed medical officer, more than fifty years ago, the district was a good one for private practice: he was a clever practitioner, and was able to live comfortably, and the salary of the dispensary was an item of small importance. By degrees the economic causes referred to deprived him of his private practice, and at 76 years of age … he found himself in bad health, too old to work, and with no money saved … With no refuge but the workhouse, as his pathetic letter to the guardians pointed out, this poor old man, victim to the Irish dispensary system, in a moment of despair put an end to his too-long life.⁴⁴

Poor Law salaries for Irish doctors were eventually raised. Undoubtedly this added to the prosperity of those doctors already in good practices but was probably of only limited help to practitioners in the rural west.⁴⁵ Sir William Thompson, physician to the Lord Lieutenant in Ireland, commented in 1905 on how far an income of £120 a year for dispensary doctors, which had become standard, would suffice in the absence of private practice. He averred that “to a man in a large town, allowed to engage in private practice, this might be a considerable sum”. A rural practitioner in the west might, however, only make £10 to £30 per annum in private practice. So that for this class of doctors,

… in what were known as the congested districts inhabited by people who had scarcely the bare necessaries of life, where there were no resident landlord class, practically no shop-keeping class and the country consisted of bogs or mountain sides sometimes thirty or forty square miles in extent, one could imagine how far £130 would go in supporting and feeding possibly a married man with children.⁴⁶

There were good livings available to the medical practitioner in Ireland but there were also doctors struggling at the margin. Some illustration of the relative situation as between Ireland and England can be given in a comparison of the wills of Irish and English doctors during this period. Several important caveats are required in using this measure. First, wills indicate wealth. As we know from the history of the Darwin family so ably recounted by Janet Browne, whereas Erasmus and Robert Darwin were both successful doctors, much of their wealth came from their industrial or financial connections, not their professional medical labours.⁴⁷ Given fewer opportunities for industrial or commercial wealth in Ireland, though there were some, the larger proportion of substantial fortunes among English doctors probably reflected the relative state of industrial and commercial development between the two countries. Ireland had some wealthy doctors but not as many as England. It also had a greater tail of doctors leaving bequests at the more modest scale of under £999.

Table 4a.

Bequests of those reaching the age of fifty and above, 1876−1910: Ireland*

Wills	Numbers	Percentages
Under £999	32	26
£1,000–£2,900	31	25
£3,000–£4,999	15	12
£5,000–£9,999	18	15
£10,000–£19,999	14	11
£20,000–£49,999	11	9
£50,000–£100,000	2	2
£100,000 +	–
Total	123

*Names were compiled at random from obituaries in the British Medical Journal and cross-checked with Probate Records for Ireland and England. Where age at death was not available, the date of first medical qualification in the Medical Directory was taken and a nominal age of twenty-five at this point was given. All subsequent years until the date of death were added to this age. This does not give an accurate age at death but, checking the procedure against instances where age at death is given, it provides a reasonable guide to whether the person falls into the age range of over fifty years at death.

Sources: obituary lists in the British Medical Journal and probated wills in Ireland (Public Record Office of Northern Ireland).

Table 4b.

Bequests of those reaching the age of fifty and above, 1876−1910: England

Wills	Numbers	Percentages
Under £999	19	15
£1,000–£2,900	31	25
£3,000–£4,999	12	9.5
£5,000–£9,999	15	12
£10,000–£19,999	22	17
£20,000–£49,999	20	16
£50,000–£100,000	2	2
£100,000 +	2	2
Total	123

Sources: obituary lists in the British Medical Journal and probated wills in the Probate Office, London.

Of doctors practising in Ireland, 26 per cent were leaving less than £999 compared with 15 per cent in England. When it came to fortunes of £10,000 to £20,000 and higher, the percentage of Irish doctors also begins to fall compared with their English counterparts. This leaves, as was suggested, more doctors in Ireland with smaller bequests and fewer with substantial bequests. However, this still means that the rewards of medical professional labour in Ireland were such that just under 50 per cent were leaving respectable legacies.⁴⁸ So, although more work needs to be done on medical income and occupational structure in Ireland, it is probable that, whilst good livings were available from private practice, there was a greater number of doctors, many of them in the rural west, struggling to build up private practice. It is a reasonable conclusion that, whereas Digby was able to conclude that three fifths of doctors in England and Wales had standard to good practices, the proportion in Ireland falls short of that.

Emigration

Throughout the period 1860–1960, Irish medical schools routinely produced more graduates than could be absorbed in Ireland. This was accepted by the medical schools as a matter of course. The Commission on Higher Education 1960–7 advised that “recognising that emigration of Irish doctors has been a characteristic feature of modern Irish society and impressed by the evidence we received on the subject, we think that in any calculation of the number of Irish doctors to be trained, allowance must be made for emigration”.⁴⁹ Ireland produced, in fact, a remarkably high proportion of the total number of medical graduates in the British Isles as a whole. Keetley's Student's guide to the medical profession (1878) opined, “If the number of students be considered, the Medical School of Dublin is larger than that of London, or indeed any other town of the United Kingdom.”⁵⁰ In 1871, according to the General Medical Council's register of first year entrants into approved medical schools, England, with 72 per cent of the population of the British Isles, produced 44.9 per cent of first year registrants. The remainder came from Scotland and Ireland who, with 27.7 per cent of the population between them, produced 55 per cent of first year medical students in the British Isles. However, in Scotland the population was rising during this period whereas in Ireland it was falling. But Irish medical schools continued to produce around a fifth of first year entrants to medical schools in the British Isles well into the interwar years.

Table 5.

Percentage of first year medical registrants for each jurisdiction to total number of registrants and to percentage of population of UK

	England and Wales		Scotland		Ireland
Year	%Population	%First Year Registrants	%Population	%First Year Registrants	%Population	%First Year Registrants
1871	72.2	44.9	10.6	27.0	17.1	28.0
1881	74.5	49.0	10.68	26.1	14.8	24.8
1891	76.9	54.38	10.6	30.3	12.4	15.3
1901	78.5	44.7	10.7	37.02	10.7	18.2
1911	79.7	42.28	10.5	36.9	9.6	20.7
1920		43.4		35.9		20.6
1925		46.3		38.3		15.3
1930		44.1		36.9		18.9
1936	81.46*	50.3	9.87*	29.5	8.6*	20.4

*After partition, the dates at which censuses were taken differ between Ireland and Britain for a short time. Therefore when calculating the 1936 figures, the England and Wales, and Scotland census of 1931 was used, but the figures for Ireland were taken from Vaughan and Fitzpatrick's figures for the 1936 Irish population. See W E Vaughan and A J Fitzpatrick (eds), Irish historical statistics: population, 1821–1971, Dublin, Royal Irish Academy, 1978, Table 3, p. 3.

Sources: computed from Census, and 'Summary of the number of medical students registered during each year, in each of the three divisions of the United Kingdom from the commencement of Student's registration in 1865 to the end of the year 1915', Medical and Dental Students' Register, London, General Medical Council, 1936, p. 15, and 'Summary of the number of medical students registered during each year in each of the three divisions of the United Kingdom, from 1905 to 1936 inclusive', ibid., p. 18.

One important outcome was the dependence of the Irish university system, as a whole, upon the medical student. The historian of the medical school of the Catholic University points out that the survival of the Catholic University was wholly due to its ability to attract students aspiring to a medical degree, whose fees saw it through its early years.⁵¹ Queen's College, Cork (a constituent member of the National University of Ireland from 1908), was also frank about the importance of the medical student to its survival. In an obituary of Bertram Windle, president from 1904 to 1919, the College, at the time when he assumed the presidency, was described as “little more than an excellent medical school which manufactured doctors for export”.⁵² The figures bear this out. In the years 1894–6 medical students accounted for around 84 per cent of the total number of students. Although this proportion dropped in the next two decades, in 1906–7 medical students still made up around two thirds of Cork's student body. Although Galway was less dependent, in 1880 57.6 per cent of the students were studying medicine. The figure fluctuated but was still around a third in 1905–6. Galway's failure to attract as many medical students as other Irish universities was, however, the reason why it was considered the most vulnerable of the Queen's Colleges in Ireland.

The medical student declined in importance as Ireland moved into the twentieth century and especially when, after the Second World War, the total numbers in higher education began to rise.⁵³ Though this did not mean that, in absolute numbers, there were fewer medical students, it did mean that they declined as a percentage of the student body.⁵⁴ None the less, each year between 1860 and 1875 there were, on average, over 1,000 medical students in Ireland, and the same is true for the period 1938–65 for the twenty-six counties of Eire alone, a remarkable continuity in a shrinking population. Irish universities were not entirely institutions for turning out doctors but, realistically, for much of the late nineteenth and early twentieth century, this was their chief function.

This meant that the Irish middle classes who invested in a medical education for their sons—and eventually their daughters—were aware that emigration might be the outcome. Though the decision to emigrate arose, in some cases, after protracted attempts at setting up practice in Ireland, in other instances, it was expected and planned for. Emigration to England could involve considerable further expenditure on top of the costs of a medical education itself.

A writer, giving advice to the newly qualified graduate of Irish schools in 1868, commented on the financial aspect of relocation in England. There were a lucky few who obtained some public appointment in England as the basis for starting a career there, but “much better than this, however, is the purchase of a partnership or the transfer of an English practice”.⁵⁵ However, a practice in London was expensive and “will fetch two years purchase”, and in the southern counties “a good practice of £500 a year will require a year's purchase especially in a market town”. Less was paid for a Midlands’ practice and less still for northern ones except in the “best towns”. Thus the new graduate would need to invest at least £300 to £500, or £1,000, but with the result that “we have known several young medical men who have done so and who are now making a large annual income, much larger than if they had remained in this country”.

Thus the purchase of a good practice in England required considerable resources.⁵⁶ But even those who worked in poorer parts of urban England could tell tales of medical prosperity. Robert Esler, a graduate of Queen's College's medical school who worked in Peckham as a police surgeon, told his compatriots in 1890 that a good living could be made by a popular, hardworking doctor even in the poorest areas of London: “Within the four mile radius there are mixed practices … But I am asked what about the 6d. men? Some of them do very well indeed. I know of one man whose practice consists mainly of club patients and 6d. fees who has two horses and as many carriages.”⁵⁷

For the less wealthy family, purchase of a practice could be made with a bank loan, loans from relatives, or by an arrangement allowing for a share in a practice to be paid back by regular deduction from subsequent earnings. Borrowing from insurance companies was another route. Occasionally, foreclosure of a run down, debt ridden medical practice meant it could be bought at a bargain price. The assumption was that the purchaser of a practice would also accede to the part-time public health and Poor Law appointments which had been held by the previous incumbent. This was not certain, but as another guide to starting a medical career put it, “It is well known that public appointments are often a leading element in the value of a practice.”⁵⁸

Another route, which relied less on family resources, was through an assistantship to a doctor in general practice, especially one that held out the prospect of succeeding to a partnership or the practice itself. The Carmichael Medical School, in the evidence they gave to the committee on remuneration in the army medical service in 1878–9, stated, “It may be added that many Irishmen at the beginning of their professional career buy partnerships in practices in England or act as assistants with the view of succeeding to a share in or the whole value of a general practice.”⁵⁹ A writer on the travails of a medical life in 1867 discussing assistantships in medical practices, asserted, “Whatever may be the cause, the fact is indisputable that a very large number of the qualified men who are now open to engagements are either Irishmen or Scotsmen.”⁶⁰ The Irish author of ‘Prospects of professional young men’ in 1868 claimed, “In a pecuniary point of view, even an assistant to a general Practitioner in England is much better off than a Poor Law Medical Officer in this country; his pay will be at least as good, he will have no expense and a horse will be kept for him when required.”⁶¹

Around a fifth of the graduates studied between 1860 and 1905 opted for medical service in the armed forces or the Indian Medical Service. From 1863 all candidates for the IMS together with those for the army and navy medical services had to take a one year course of study at the Royal Army Medical College at Netley leading to an exam.⁶² Even with the additional expense involved in this, a medical career in the military did not have the risks associated with setting up in practice if money, friends or connections were in short supply. It was regular work, pay increased on active service, and retirement on half pay was allowed after twenty years. There was also a progression from assistant surgeon to surgeon and then surgeon major. A pattern is observable in military careers where, by retirement, most had at least a few years in the rank of surgeon major. Even before the increases in income recommended by the 1878–9 committee, the initial starting salary matched and even exceeded the immediate pay of public appointments—except for lunatic asylums and some county infirmary boards.⁶³ The report of 1878–9 recommended improvements in the pay and conditions of those serving as doctors in the army and colonial service, and this meant in 1885 retirement on a £1 a day pension and an honorium of over £2,000, allowing for the possibility of purchasing a practice. Moreover a military career had positive attractions. It offered a wide range of opportunities, and some doctors made notable careers out of the army and IMS.

All these economic calculations influenced decisions about emigration. But it is also important to emphasize another point. Some medical emigrants to Britain looked upon emigration as the “last resort” driven by relative poverty; others found the additional costs it might incur a burden. But Rosemary Stevens's observation about another generation of medical migrants—that they did not always come from the poorest families—also applies.⁶⁴ Emigration could offer the possibility of a distinguished and lucrative medical career elsewhere. The lure of rewards and honours stimulated emigration, and many saw it in this light. For some families, therefore, emigration was the first choice rather than the last resort.

Migration to Britain was based on the assumption of a common medical marketplace, a similarly regulated profession and cultural affinities. It was not until 1922, on the independence of twenty-six counties, that it would involve—for a part of Ireland only—crossing national borders. Even then, no formal legal barriers existed to the movement of labour between the two islands. Ireland's medical schools were still represented on the General Medical Council of the United Kingdom and subject to periodic inspection by the GMC.

Was it therefore emigration? Whatever the links, migration to Britain was certainly seen as removal. A distinct sense of difference and of nationality remained. One of the more visible manifestations was the Irish Medical Schools’ and Graduates’ Association founded around 1877.⁶⁵ By 1880 there were 189 members. Most practised in Britain where the Association's annual meetings and dinners were held. By 1888 there were 514 practitioners on its roll.⁶⁶ It could not be said to have covered all emigrant Irish medical graduates, and 1899 Dr Stewart, the provincial honorary secretary, claimed that there were “2,000 practitioners resident in Great Britain who were eligible for membership but were not yet enrolled”.⁶⁷

Part of the Association's remit was to represent the particular grievances of Irish medical emigrants—particularly the preference given in some appointments in England to the degrees and diplomas of the London colleges.⁶⁸ At the same time the convivial atmosphere of its annual dinners, to which distinguished visitors were invited, were also an opportunity for the celebration of Irish patriotism and uniqueness. At the annual dinner of 1880 held in Cambridge there was a particularly eminent company of visitors. “Mr Lister said he never dined in the presence of Irishmen without feeling an irrepressible sense of envy for the natural gift of eloquence that had been bestowed on them”, whilst Dr Brown-Séquard confessed “his grandmother was an Irish woman and so he possessed a little of that blood”. Dr Gross of the USA said he “recollected when quite a boy in his profession, with what benefit and what interest he read many works emanating from the Dublin press, he had been charmed with the writings of the late lamented Stokes and the like lamented Graves—names engraved in the heart of every Irishman who knew anything of medicine”.⁶⁹

This sense of national identity could take various forms. Turner J Fisher, a graduate of Queen's College, Belfast, in 1875, after taking a master's degree, relocated to 14 Portland Place, Lower Clapton, in London, and then moved to Hackney. Over the years he collected various emoluments, becoming by 1885 medical officer for the General Post Office and for the fourth and fifth districts of the Hackney Union, as well as officer for the London Clerks Association and the Old Gravel Pit Association. He remained in London throughout his professional life, his last appearance in the Medical Directory being in 1920. Fisher, none the less, named his house in Hackney “Carnalea” after a small village near Bangor, County Down. Robert Esler, his fellow graduate from Queen's College, Belfast, in 1875, began his career at the Ulster Hospital for Women and Children, becoming president of the Ulster Medical Society. His strong commitment to the area is shown in his publication of a guidebook of the scenic beauties of Antrim in 1884, and a history of early Belfast medicine in the same year.⁷⁰ But by 1885 he had moved to Peckham. His duties there included, as well as general practice, the post of medical officer for the “P” division of the Metropolitan Police. Esler's address was still in Peckham in 1915. Though removal to England attenuated his links with Ulster, he retained professional and personal connections with Ireland. He published in 1887 in the Transactions of the Ulster Medical Society on ovariotomy, and in 1890 on his experience as a police physician in London. Esler summed up his feelings on his departure in this fashion:

I miss your Medical Meetings—the Medical Societies of London are four miles distant—and I miss my many old friends. I have no Dill nor Whitla nor M’Kenzie to interchange ideas with, nor have I any hospital work nor student classes to prepare for; but I have, in exchange, a remunerative practice, good health, a happy home and am a citizen of no mean city.⁷¹

Conclusion

For most of the period 1860–1960 Irish medical schools were exporting schools. Assumptions that they would produce more graduates than could be absorbed in Ireland were built into their calculations. There was an expectation that opportunities for making a medical living outside Ireland would routinely be considered upon graduation or shortly after. This influenced advice and admonitions to graduates. Parents and students accepted that this might be the outcome of a medical education. For those who remained in Ireland, a medical career could provide similar emoluments to those in England. A stratum of doctors existed in Ireland whose rewards from medical labour were commensurate with the respectable incomes of their English counterparts. But there were, at the margins, poorer rewards from private practice, leading to greater dependence on the Poor Law appointment. This acted as a push factor for emigration.

However, it was not always the poorest—those with diminished opportunities in Ireland, or those who were disappointed in their expectations of making a medical living there—who emigrated. Emigration represented opportunity too. The anticipation of a good living in England, the excitement of the metropolis or larger town, and the opportunities provided by empire also exerted a pull upon the Irish medical graduate. Sir Thomas Myles, addressing the graduates of the Royal College of Surgeons in Ireland in 1901, put this choice to his audience. They could embrace “a life of servitude” aggravated by the “insane competition for the position of dispensary doctor” against “a vista of success in one of the large towns of England or subsequently settling in one of the colonies”. He was not, he opined, “urging you to emigrate; to do so would, I know, bring down on me the wrath of many well meaning people who think that Irish workhouses are not sufficiently overcrowded”. But he urged graduates to “shake themselves free from the spirit of narrow parochialism and strike out boldly for the big prizes that are available to you”. This meant that: “It is our fashion to rail against the British Empire and all that pertains to it. But don’t forget that under the flag of that Empire and thanks to the growth of that Empire, thousands of Irish medical men are making a comfortable living and hold posts of honour and emolument in every part of the globe.”⁷²