Chapter 4 ‘ A Few Deaths from Hunger Is Nothing ’ : Experiencing Starvation in Irish Prisons , 1917 – 23

What does it feel like to be on hunger strike? What actually happens, physically and emotionally, to fasting prisoners? And how do doctors interact with hunger strikers when they are not allowed to force-feed? In many ways, the problems created by allowing prisoners to starve are similar to those posed in euthanasia debates. These centre on whether physicians should withhold treatment to let a patient die if requested, an act normally seen as ethically preferable to actively killing a patient. In such circumstances, physicians tend to value the principle of patient autonomy but consider their options in light of ethical and legal considerations. However, hunger striking presents a slightly different quandary. Hunger strikers do not normally wish to die, although they are willing to do so if absolutely necessary. Also, unlike euthanasia patients, their intention to die usually stems from political agendas, not from any desire to escape from pain or suffering through death. Dying in no way benefits a hunger striker, although it can certainly aid his or her broader political cause. To further complicate matters, prison doctors are normally dealing with patients in the prime of their lives who would be perfectly healthy if they simply resumed eating. Unlike euthanasia, hunger strikers inflict pain and suffering upon their healthy bodies and refuse medical intervention; they manipulate and damage their own bodies for a broader political purpose.

Using the case study of revolutionary-period Ireland, this chapter examines prisoner experiences of fasting. Using autobiographical evidence, it recaptures historical experiences of hunger striking to illuminate the physical and emotional consequences of hunger striking, the means of coping developed by prisoners, and the structuring of prison medical encounters. Relatively little is known about what happens to the human body without food. It would be somewhat unethical to starve a healthy human being for research purposes. Moreover, politicised hunger strikers are rarely, if ever, willing to be monitored for experimental purposes. The scientific writing that exists on what happens to the starving human body tends to be highly technical; it fails to communicate the human suffering involved in the spectacle of starving oneself. Yet it is this physical and mental anguish that captures the attention of a sympathetic public. Hunger striking is an intensely personal act involving a body in distress. Yet the suffering body also has immense rhetorical potential. Bodily pain might be experienced privately behind the enclosed walls of the prison, but it reaches out to a public sphere that shares particular discourses on civility, compassion, and the need to avoid senseless deaths.
Between 1917 and 1923, group hunger strikes were allowed to run their course for the first time, occasionally to death. After 1917, Irish prison doctors could no longer cling to their argument that they had an ethical duty to forcefeed fasting prisoners. The procedure had become far too associated with violence, torture, and brutality. But perhaps many doctors genuinely saw force-feeding as a lesser evil than watching patients inflict a slow, agonising death upon themselves. Exacting pain with a stomach tube certainly clashed with the medical ethical norms of the day. But allowing prisoners to die without intervening was equally problematic in a socio-cultural context that placed high value on the sanctity of life. Today, doctors in most countries are obliged to maintain distance from hunger strikersto observe, but not halt, their gradual disfigurement and deterioration. They cannot hinder a slow descent into death as the personal autonomy of hunger strikers is now respected. When faced with a hunger striker, doctors are advised to establish trust, inquire into whether the protest will be short or until death, and determine whether the prisoner will allow physical examinations, weight measurements, daily visits, and hospitalisation. Doctors also ensure that hunger strikers understand the likely consequences of refusing food. As mental deterioration (accompanied by a loss of competence) occurs in the later stages of a hunger strike, physicians are advised to obtain a living will type advance directive that would guide them in conforming to the patient's wishes if starvation progressed to coma stage. Forcefeeding is only permissible when a hunger striker seems incapable of forming a rational judgement (although American courts have regularly failed to support the right of a rational prisoner to choose to starve).
To shed light on such issues, this chapter examines the transition away from force-feeding policies in Ireland following Thomas Ashe's death in 1917. Historians of the Irish revolutionary period have mostly focused on the small number of hunger strikes that actually ended in death (most notably that of Terence MacSwiney) at the expense of numerous non-fatal protests. Yet between 1917 and 1923, thousands of hunger strikes took place in Ireland. William Murphy has provided a broader narrative which details many of these protests. But deeper analysis of doctor-patient relations and the decaying hunger striking body itself could offer insight into the broader issue of how doctors and patients in conflict areas interact and cope with the physical and mental strain of hunger striking. Unlike forcefeeding, self-starvation is something done to one's own body; it raises few claims of unwarranted assault and bodily violation. In the late 1910s, this radically altered doctor-patient relationships. In fact, tensions eased considerably between Irish doctors and hunger strikers. Many doctors felt compassion and sympathy towards their fasting patients. In light of this, prisoners began to experience hunger striking differently. They felt pain, discomfort, and hallucinations as hunger took its natural course. Some prisoners progressed to coma stage as their bodies finished depleting natural fat reserve supplies. Although traumatised, hunger strikers enjoyed more positive interactions with their doctors than had been the case when the government supported force-feeding. Once the personal autonomy of a patient began to be respected, something closer to a normal medical encounter occurred. Nonetheless, the extent of bodily harm inflicted during a hunger strike can help to explain why some doctors might consider force-feeding as ethically preferable to allowing prisoners to starve themselves to death.

Changing Relations
From 1917, new relationships were forged around hunger striking prisoners. Prison doctors fashioned new identities as helpless overseers of death; prisoners transformed from torture victims to political martyrs; hunger striking evolved from a last resort of the seemingly irrational to a form of spiritual sacrifice. Thomas's death made clear, even to advocates of 'artificial feeding', that the procedure was potentially dangerous, life-threatening, and incompatible with standard therapeutic care. Although the government never formally conceded that force-feeding could be unsafe, even despite a prominent prison fatality, its enthusiasm for resorting to the stomach tube in Ireland swiftly waned. There, force-feeding was now highly contentious.
Thomas's death occurred during a period of strain in Anglo-Irish relations caused by the controversial execution of the leaders of the 1916 Easter Rising, delays in implementing Home Rule (postponed indefinitely until after the First World War), antagonism towards plans to impose wartime conscription in Ireland, and vexed debates on the idea of partitioning Ireland to appease Ulster Unionists in the north of the country who remained loyal to the British state. This turbulent backdrop ensured that what could have been an isolated prison incident transformed into a national scandal. Republicans harnessed Ashe's death as emblematic of British brutality. In the turbulent years that followed the First World War, Irish prisoners went on hunger strike with remarkable alacrity. From 1918, political and social tensions between England and Ireland intensified. In the general election of that year, republican political party Sinn Féin gained 73 seats in Ireland out of a total of 105, although Unionists retained a majority in the northern province of Ulster. Sinn Féin members refused to take their seats in the House of Commons and pledged to set up an autonomous Irish parliament. The First Dáil government (legally unrecognised by the British government) met for the first time in January 1919 at Mansion House, Dublin, and declared that England and Ireland were at war. The Irish War of Independence followed, a period of national violence in which the IRA, the army of the self-proclaimed Irish Republic, fought a protracted guerrilla war against the British government and its forces in Ireland. The autonomous Irish Free State was established in 1922, although conflict ensued between two opposing republican groups over the contested terms of the Anglo-Irish Treaty which left six counties in the north of Ireland within the UK. Contestation over this matter resulted in the Irish Civil War (1922-23), a violent conflict between pro-and anti-Treaty factions of the republican movement.
The extent of hunger striking during these conflicts placed tremendous pressure on the Irish prison service. Michael Biggs has estimated that between 1916 and1923, prisoners and internees staged approximately 10,000 hunger strikes. The vast majority gained concessions. Many were released. This severely undermined policies of imprisonment and internment and demoralised the police and military forces who wondered why they were bothering to arrest republicans only to see them prematurely released while on hunger strike. The numbers of republican prisoners willing to hunger strike en masse took a mental toll on prison medical staff. In 1916, a doctor at Frongoch internment camp, Merionethshire, Wales, threw himself into a quarry reportedly due to the mental stress of dealing with up to 200 fasting Irish prisoners. In the House of Commons, nationalist politician, Laurence Ginnell, insinuated to the Home Secretary that this doctor had committed suicide after being forced to perform an 'act of cruelty', a tacit reference to force-feeding. During the War of Independence, hunger strikes formed part of a broader republican strategy of undermining the British administrative system (also reflected in the targeting of Royal Irish Constabulary officers). As republican publicity officer, Frank Gallagher, asserted, 'by smashing the prison system we become free to continue the smashing in Ireland of their Empire … a few days' hunger in payment for such a blow is nothing … even a few deaths from hunger is nothing.' For such reasons, thousands of prisoners staged hunger strikes. During the subsequent Civil War, anti-Treaty Republicans went on hunger strike to protest against the mass imprisonment of prisoners who felt betrayed by the creation of an independent state without the six northern counties. In October 1923 (five months after the conflict had formally ended), around 7800 anti-Treaty republicans initiated a mass hunger strike.
During this period of intense socio-political tumult, it became evident that policies of allowing self-starvation harboured their own set of ethical problems. Starving prisoners suffered from a spectrum of physical, psychological, and emotional conditions, but mostly refused therapeutic care. How did prison doctors transition from being perpetrators of force-feeding to carers of the starving? As early as 1912, George Bernard Shaw had recognised the precariousness of allowing prisoners to starve. In a letter published in the Irish Times, Shaw had commented that 'as long as the Government placed within the prisoner's reach a sufficiency of food, I do not see how it could be held responsible for the prisoner's death'. Nonetheless, Shaw fully appreciated the emotional complexity of hunger striking and the degree of public feeling likely to emerge should a prison death occur, even if staff had provided food. The government could still be held responsible if seen as having created or supported the conditions that encouraged prison protest or as having obstinately failed to concede to reasonable demands. Shaw perceptively added that if 'the suffragists in Mountjoy are allowed to kill themselves, the sorrow which such an event will create, in spite of all logic, will be inspired by the Government and not by the victims. And that is the final weakness of the position of the Government'. For Shaw, the emotional consequences of a prisoner starving to death would always outweigh the logical, but less impassioned, argument that death was something a hunger striker had brought upon him/herself. Shaw also alluded to the problem of prematurely releasing prisoners committed for serious crimes (in this instance, arson). As he observed, 'to release a really dangerous criminal after a fortnight's stomach pumping would be ridiculous.' The inherent dilemma for the government was that concessions (such as early release) or prison deaths were both negative outcomes. Moreover, the government also feared that if it yielded to hunger strikers, then further politicised prisoners would go on hunger strike, as well as convict prisoners. But a prison death would only strengthen public perceptions of the sacrificial (rather than suicidal) hunger striker, bolstering public support for the prisoners and their broader cause.
How, then, did policies change? By 1917, force-feeding was widely agreed upon in Ireland as hazardous, whether performed on men or women. The fact that a stout, strong male body had succumbed to the effects of the procedure strengthened the case against force-feeding. Irish newspapers emphasised Thomas Ashe's strength and brute masculinity to demonstrate antipathy towards the procedure. The King's Co. Independent reported his death under the heading 'he was of magnificent physique', adding that 'he was generally spoken of as the man who would be able to hold out longest and bear the hardship and its ill effects'. The stomach tube was no longer simply a weapon used against physically and emotionally frail female prisoners. It was now portrayed as a potent weapon that could subjugate-even murder-muscular Irish prisoners.
Meanwhile at Mountjoy, prison staff had to decide what to do with those prisoners still on hunger strike in the tense days that followed Ashe's death. At the end of September, a Board assembled at the prison to find a solution. It concluded that 'artificial feeding' did little to uphold the health of prisoners after all. Accordingly, the Board recommended the conditional release of thirty-nine prisoners including Austin Stack. In November, Dublin Castle instructed Irish prison governors that prisoners should only be force-fed by special order and should recommend temporary discharge under the Cat and Mouse Act if physical collapse seemed imminent. A further memorandum dispatched to Irish prisons in November from the Under-Secretary for Ireland, William Byrne, instructed that 'any prisoner, whose condition in the opinion of the medical officer requires it, should immediately be released without waiting for further authority'.
Force-feeding was by no means ruled out. Yet, in Ireland, the tide had turned firmly against the procedure. Doctors who force-fed found themselves subject to strong public censure. In January 1918, Mountjoy's medical staff force-fed Sinn Féin prisoners, James Roche and Edward Horan, raising protests from Count Plunkett and Irish MP (and future president of Ireland) Seán T. O'Kelly. They fed Edward for nine days and James for ten before recommending temporary release. Dowdall, O'Carroll, and Cooke refused to continue 'artificial feeding' for any longer unless a Commission or Committee represented by expert medical opinion endorsed such a decision. Given Dowdall's fervour for feeding politicised prisoners, this was unexpected. He presumably felt little concern about James and Edward's welfare. However, he was reluctant to be placed once again in a legal scenario where he might be forced to assume responsibility for death or injury. Dowdall was now feeding prisoners in the face of high public sensitivities. Upon being released, eighteen-year-old Edward complained to an Irish Independent journalist that he had vomited blood while being fed. Dowdall wrote privately to the General Prisons Board stating that he had stopped feeding upon noticing this blood and that Roche's gum complaints had been self-inflicted. Nonetheless, the sight of blood seemed to have finally encouraged Dowdall to put down his stomach tube once and for all.
During the War of Independence, force-feeding was performed occasionally, but strong public feeling ultimately deterred prison doctors. When doctors at Limerick Prison force-fed a number of prisoners in February 1919, public anger mounted. Two months later, the Limerick Board of Guardians refused to appoint Dr McGrath as a dispensary medical officer due to his involvement in these feedings, even though McGrath had temporarily held the post for the past three years. In 1920, the unexpected removal of three prisoners from Cork Prison stirred excitement when a Cork Examiner journalist reported that the men, close to death and spitting blood, had been removed to Cork Military Hospital to be force-fed. He commented: It is not sufficient that these brave men should die, as Thomas Ashe had died, in defence of a principle. Their deaths must be made agonising and their bodies and souls tortured by the refined brutality of forcible feeding. Such are the methods a British government has been reduced to in its brutal attempt to destroy the soul and spirit of the Nation.
One prisoner, Maurice Crowe, later recounted that he had indeed been informed that he was to be fed. However, negative media coverage seemed to have discouraged the prison doctors. As an alternative solution, the prisoners were transported to Pembroke Prison, England, where a further attempt was made to feed them.
The British government never quite admitted that it no longer force-fed Irish prisoners. Senior politicians carefully evaded questions raised in the House of Commons about whether politicised prisoners were still being fed.
Abandoning the rhetoric of 'artificial feeding' would have required backtracking on a decade of official statements on the safety of the practice and conceding some degree of responsibility for Ashe's death. It seems plausible that the government was also reluctant to entirely dispose of a potent weapon in its artillery at a time when Irish prison rebellion was intensifying. Nonetheless, both Dublin Castle and the British government remained cautious about force-feeding republican prisoners in Ireland, fearing it would prove too politically contentious. Moreover, the large numbers of prisoners on hunger strike during the War of Independence made the option less feasible. Considerable medical facilities, staffing, and resources would have been required to feed such a large number of prisoners. Even if these had been available, force-feeding occupied a dubious position in the Irish national psyche. It stirred resentment among the public as the stomach tube was now implicated as a lethal weapon in the ongoing Anglo-Irish struggle.
This scenario set the stage for new forms of hunger strike management and the formation of new relationships between doctors and prisoners. If, by 1917, force-feeding had been broadly agreed upon as unethical, it seemed that the Home Office and prison authorities had only two options left as predicted by Shaw: recommend early release or allow starvation to run its course. In February 1918, Mountjoy officials began to inform hunger strikers that they would neither be fed nor released. In the following month, John Irwin warned prisoners that the government was determined to stop authorising releases under the Cat and Mouse Act. This policy shift caused immediate unease among prison medical staff. Many still believed that death could occur in a matter of days of hunger striking. In 1912, the General Prisons Board had invited Dublin physician, Joseph O'Carroll, to Mountjoy to offer his expert opinion on how long Mary Leigh and Gladys Evans were likely to remain alive without eating. Leigh and Evans had been hunger striking for just two days. O'Carroll observed that the prisoners already appeared weak and cold, noting an acetone odour on their breath characteristic of starvation cases. He concluded that Mary and Gladys were already suffering physically from starvation and that de-nutrition was firmly established. If their protests continued, O'Carroll warned, the frail bodies of the prisoners would rapidly decay as their reserve supplies of consumable tissues expended. O'Carroll ominously predicted that 'it is dangerous to their lives to allow the starvation to go further'. Evidently, prison medical staff shared a deep-rooted fear of the rapidity of human starvation during the suffragette hunger strikes. O'Carroll firmly believed that prisoners could endure starvation for just two or three days. In the 1910s, this belief had underpinned-indeed justified-force-feeding policies and informed decisions to resort to the stomach tube at an early stage of a hunger strike.
An absence of force-feeding policies changed the function of prison doctors who were no longer accused of torture but instead forced to adopt an uneasy palliative role in cases of severe prisoner health decline. Did this in any way ease the pressures that had been placed on certain prison medical staff since 1909? Initially, some doctors continued to intervene. When IRA ( He had me turned lying on my face and I got the impression he was doing something he shouldn't be doing in the way of forcible feeding, not in the way it was done in Mountjoy but forcible-feeding of another kind. I said "What are you trying to do?" and he said "I am giving you something to keep up your strength". "Well, my God", I said, "If you continue you may overpower me, but I'll tell you this, whenever I get out, or I will get word out somehow, I will have you killed". I was under the impression he was giving me forcible-feeding through the posterior passage. He desisted and said "I have only been trying to save your life".
It is unclear from this account whether O'Flaherty had been persuaded by senior prison staff to attempt a surreptitious rectal feeding or whether the doctor had acted on his own initiative to preserve Eamon's life. Nonetheless, O'Flaherty presented his actions as an act of kindness and sympathy. As Eamon continued: Most of these doctors then thought that a week's hunger strike was dangerous. They got to know as time went on that a month's hunger strike wasn't a danger to a great many men. He said he was sorry. I said, "That's all right as long as you don't do it". He said, "It is a heartbreak for me to have you here, and if you die on my hands what will I do? Do you suggest I release you and lose my job?" "I have not suggested to you to do any such thing", I said, "and I have not asked you to release me. Don't do anything that will do yourself harm, Dr O'Flaherty. Don't try anything like forcible-feeding but, at the same time, I will let the hunger kill me before I will give up".
Eamon's narrative suggests that he formed a relatively compassionate relationship with his doctor once force-feeding policies had been abandoned. O'Flaherty appears to have held conflicting emotions towards caring for a prisoner whom he believed to be dying ranging from genuine pity to a fear of being dismissed from his post. O'Dwyer appeared equally sympathetic to his prison doctor, perhaps realising the precariousness position of institutional medical staff as unwilling intermediaries between the government, prison officials, and republican prisoners. Eamon took care in his account to note O'Flaherty's concern with keeping him alive, despite firmly objecting to the attempted rectal feeding. It seems that O'Flaherty believed that feeding was preferable to death.
Notably, prison doctors still felt anxious about the potential legal implications of a prison death. In February 1918, the General Prisons Board suggested that legislation was urgently needed to protect medical staff against potential manslaughter charges. Many doctors remained ambiguous about overseeing self-starvation. Frank Gallagher recalled on his twelfth day of a hunger strike at Mountjoy Prison that his attending doctor seemed more afraid of a fatality than the prisoners themselves. 'He has stopped smiling, the doctor', Frank claimed, 'why should he be afraid?
The men are not afraid-except a little at night when the mind will not stay quiet, but even Christ had that physical fear'. Medical staff working in hospitals close to prisons were also concerned about their legal standing. In the same month, Limerick County Infirmary physician, J.F. Devane, telephoned the General Prisons Board to discuss a hunger striker under his care. Devane announced that he would take no responsibility should the prisoner die. Evidently, new hunger strike management policies caused disquiet among medical staff. Those who had previously force-fed had the safeguard of medical duty to fall back upon, as well as the legal precedent of Leigh v Gladstone. Yet being expected to oversee death was uncharted ethical and legal territory. It was only in 1920 that the government clarified the position of prison medical officers by formally specifying that civil or criminal responsibility for a death would not rest on a staff member in charge of a hunger striker. But other threats existed. Prison staff maintained an uneasy relationship with the IRA who regularly dispatched death threats to prisons where a hunger strike was taking place. One posted to the Governor of Cork Prison in 1920 read: 'If any of these men are allowed to die, the soldiers of the Irish Republican Army in this country will at once take action of the most drastic kind to avenge the murders.' For many reasons, certain prison doctors in Ireland refused to participate in hunger strike management with the enthusiasm desired by the General Prisons Board as they either sympathised with the prisoners or had little desire to become entangled in the exigencies of conflict. When the General Prisons Board requested that Dr Flynn, medical officer at Cork Prison, write a separate medical report for each prisoner, Flynn emphatically refused unless he was paid a guinea per hunger striker, adding that 'they can throw me out if they like'. Flynn insisted that the hunger strike was a moral cause requiring daily visits by a chaplain, not a medical problem. Earlier, Flynn had refused to forcefeed. Similarly, in June 1920, Flynn made clear in a telephone message to the General Prisons Board that he would assume no further responsibility for one ailing hunger striker under his care and recommended his immediate transfer to a local hospital. Flynn regularly endorsed the early release of prisoners by claiming that they were suffering from conditions such as valvular heart disease or myocardial degeneration. His zealousness in diagnosing heart conditions soon drew the attention of members of the Board who began to over-rule his recommendations. Whereas force-fed suffragettes and republicans such as Thomas Ashe had been emotively presented as powerless, vulnerable victims of a government intent on causing physical harm with the use of medical technologies, it seems clear that starving hunger strikers possessed greater control of their actions. They had more autonomy than force-fed prisoners, particularly if they possessed the self-control and determination needed to abstain from food indefinitely for an important moral cause: securing an independent Ireland. The shift towards permitting self-starvation allowed hunger strikers to become actively involved in their own institutional fate and harness control of their environment in a manner that the passive, but aggressively weakened, victims of force-feeding had been unable to. They had been granted permission to subvert the normal disciplinary workings of the modern prison by reclaiming bodily autonomy. Diverse encounters ensued between medical staff and hunger strikers. Most doctors felt uneasy about overseeing selfstarvation. Although some were undoubtedly wary of courting adverse publicity or being prosecuted, others sympathised with the hunger strikers (perhaps irrespective of whether they agreed with their broader cause). Doctorpatient interactions were now discernibly more compassionate in nature.

Experiencing Starvation
What is it like to be on hunger strike? How is fasting experienced physically and emotionally? And do doctors perceive the distressing spectacle of self-starvation as any less problematic than force-feeding? Republican prisoners left an abundant supply of autobiographical material that offers insight into deeply personal aspects of their hunger strikes. These differ from sources such as suffragette propaganda as they were mostly written, recorded, and published long after the revolutionary period. In contrast to suffragette accounts of force-feeding penned during their campaign for the vote, most autobiographical republican literature was not intended to stimulate immediate change in state policies or attract public support for a pressing political cause. It was written some time after. First-person testimony of prisoner experiences is contained in sources including the Bureau of Military History oral history witness statements collected by the Irish state between 1947 and 1957 and in published accounts such as Frank Gallagher's Days of Fear (1928). The physical, psychological, and emotional strain caused by abstaining from food figures prominently in their accounts, indicating that hunger striking occupied a central place in the shared memory of the War of Independence and Civil War and informed how republicans subsequently articulated their historical experiences.
The production of these sources inevitably involved a certain extent of retrospective self-fashioning that reflected a tendency in independent Ireland to remember those involved in the events leading up to independence as heroic and victorious. While some authors openly admitted that they considered abandoning their hunger strikes, the overwhelming majority emphasised their determination and resolve to persevere with fasts that sometimes lasted for weeks. As Alannah Tomkins argues, the process of self-presentation historically embodied in the production of autobiographies can influence the inclusion and omission of events. Moreover, many autobiographical texts or interviews make extensive use of established motifs or narratives. Certainly, sources such as the Bureau of Military History witness statements tend not to provide details on prisoners who refused to participate in group hunger strikes or who gave up after a few days. Oral history sources are also notoriously problematic due to issues such as memory, bias, and impartiality. In addition, Gallagher was a master at producing republican propaganda meaning that his rendering of his prison experiences was structured by the impression which he sought to create of his endurance for the cause of an independent Ireland. From republican perspectives, the prison was not a site of personal rehabilitation but a space in which injustice (often, internment) existed, a view that ensures that the hunger strike narratives recorded in this format depict a bodily struggle and, in many instances, victory against a multitude of institutional and state forces.
On a quiet evening at Mountjoy in 1919, prison staff heard an unexpected commotion. Upon inspecting, they encountered a group of republican prisoners setting fire to their beds, smashing their windows, and wrecking their cells. A clear signal had been sent: A hunger strike was underway. The prison warders subdued the rebellious prisoners with fire hoses. It was common for prisoners to announce hunger strikes with displays of disruptive behaviour. In 1920, fifty prisoners broadcasted their intention to hunger strike at Wormwood Scrubs by simultaneously tearing down their cell doors, initiating a battle of wills between staff and prisoners. Prison warders placed steamed kippers in the prisoners' cells, hoping to entice them to eat. Windows were smashed and the food thrown outside. A member of the Home Office then visited the prisoners promising concessions if the protest was called off. The prisoners refused to move from their beds to listen to him. Five days into the protest, warders began to supply better quality food to all prisoners. The hunger strikers refused to budge. Starvation was allowed to ensue. At the time, doctors knew very little about the physical and emotional processes of starvation. They learnt gradually through day-to-day observation. Scientific research into human starvation was in a nascent state. American physiologist, Francis Gano Benedict, had published an important study in 1915 based on his observations of a man who had agreed not to eat for thirty-one days. Yet it is unlikely that English and Irish prison doctors were familiar with this research. Physiology tended to be viewed as a somewhat abstract discipline with relatively little clinical value. In many ways, the bodies of prisoners generated knowledge as they decayed. Attending physicians learnt to recognise characteristic symptoms such as decreasing heart rate and physical wasting, even if the precise nature of the physiological processes of starvation remained unclear. They saw the bodies of hunger strikers rapidly decay during the first week of fasting, arousing fears of imminent death. Indeed, the speed of this initial decline had previously encouraged prison doctors to force-feed. The hunger strikers' bodies were quickly exhausting the fat reserves held in the adipose tissue. Once these had depleted, their bodies set to work consuming the glycogen stores, a secondary energy store located in the liver and muscles. Ammonia was produced at this stage, creating the distinctive smell observed by Joseph O'Carroll when he visited the suffragettes imprisoned at Mountjoy in 1912. However, this ammonia was then excreted with keto acids to spare sodium loss and decrease the speed of weight loss. Physical decay began to slow. Doctors also saw other physical symptoms at this early stage including a loss of heart mass and the development of bradycardia, a resting heart rate of less than sixty beats per minute. It was this slow pulse that had encouraged doctors to force-feed just days into a hunger strike and pay close attention to the heart rate of prisoners including Constance Lytton (but less so with Thomas Ashe).
During their first week of hunger striking, prisoners experienced various physical and emotional sensations. Sinn Féin MP, Constance Markievicz, privately wrote, 'I only did three days and I was quite happy and did not suffer at all. I slept most of the time and had lovely dreams and time went by quickly.' Many prisoners felt surprisingly little longing for food. Frank Gallagher recorded in his diary: [I] noticed in yesterday's papers that some French journalist spoke of our 'pangs of hunger'. Nobody would ever believe that there are none. There is revulsion at death, a wild longing to live, but no physical call for food. That ceased on the second day. Now tastes and smells are pleasant to think of, but mean nothing. If the mind took the fast as quietly as the body does, the whole thing would seem like a joke, there would be so little suffering in it. If our friends outside would believe this. But it is true and they never will.
Others seemed to have coped less well. IRA (Southern Division) member Seán Moylan recounted: Day after day I found my mind preoccupied with the devising of menus. Elaborate and often incongruous combinations of food-flesh, fruit, vegetables-passed on the assembly belt of imagination before my eyes leaving the craving that encompassed me more insistent as the days went by. At no time, however, did this delicious dream of food tend to weaken my determination to continue the strike. Spirit triumphed over matter … it makes clear the point that before a man can live spiritually he must have a physical being; the measure of man's spiritual development is the extent of his control over the body's demand.
Despite recalling contrasting experiences of food cravings, both Frank and Seán called attention to the pride that they felt in having conquered physical hunger using will power and mental determination. Seán, in particular, presented his struggle against hunger as a spiritual feat, exemplifying the sense felt by many imprisoned republicans that hunger striking served a spiritual purpose.
Feeling hungry was not the only problem. Prison meals were central to the monotonous sense of time and routine that structured prison experiences. Food serves important disciplinary purposes in prisons. Tedious meals and the serving of poor quality food can form part of the punitive landscape of the prison, providing a potent reminder of the liberties that prisoners leave behind after choosing to commit crime. Nonetheless, by refusing to eat, hunger strikers severely disrupted their daily routines. After seven days of hunger striking, Frank Gallagher recalled: Tonight my head aches. Those first days of hunger-striking are cruel days. Yet the hardest thing of all to bear is that there are no meal hours. Jail life hinges on the three meals. It is morning, and one is brisk and vigorous because the tin at the door has porridge in it. It is afternoon, and a calm studiousness invades the mind because the contents of that tin are soup and potatoes. It is drowsy evening, and one begins to yawn because soup and potatoes have given way to cocoa and crusted bread and now there is no division of the day, no beginning and no end. The head aches, the body is damp and weak. Even sleep has gone. The lack of institutional routine without food seems to have deeply affected Gallagher who faced monotony and boredom without the distraction of meal times to break up the tedium of institutional life. After eleven days of hunger striking, Gallagher began to rave about clocks, perhaps a further indication of the centrality of perceptions of time to his experiences.
Until 1920, prison doctors remained highly concerned about the prospect of death during this initial stage of fasting.
Reportedly sympathetic doctors at Limerick Prison tended to release hunger strikers after seven days without food. Prisoners also played on the fears shared by their doctors. Robert Brennan was imprisoned at Cork Prison during 1917. He later recalled that the prisoners deliberately made medical staff nervous by constantly pretending to be ill. On one occasion, Robert recollected, 'when the strike was only five or six days old, we arranged that one of our fellows should collapse and be carted off to hospital, but before he could do so, another man actually did collapse. The doctor, in a panic, recommended our immediate release.' Similarly, Terence MacSwiney once jovially placed his bare feet on the cold hot-water pipes while hunger striking prior to a visit from his prison doctor. Cold feet were recognised as a symptom of heart disease. Seán Moylan went further. He decided to feign insanity. When being examined by the prison doctor, Moylan refused to do anything but snarl when touched. Upon being provided with food, Seán leapt frenziedly out of bed, grabbed the tray, and hurled it at the window shouting 'poison' repeatedly. Rumours circulated around the prison that a hunger striker had gone insane. Prisoners kicked down doors and broke windows. Seán later recalled that 'the unfortunate prison governor and doctor were far nearer to mental derangement than I ever pretended to be'. We were taken out of the cells where we were and thrown into what are called punishment cells. We were three days on hunger strike at this time and were getting pretty weak. These punishment cells are in the basement, low down. They had not been opened for twenty years, I think. They were very small and close and the dust was thick in them.
Denis added that the size of the cells was only twelve by eight feet and that the prisoners remained imprisoned there for four days without being offered water to wash with. Similarly, IRA (Derry Brigade) member, Patrick Rankin, recounted that Wormwood Scrubs prisoners were forced to share single cells with up to five other prisoners. Rankin recounted that 'our health was not going to be improved under those conditions … in our ground floor cells we were packed like cattle-no room, poor ventilation, overcrowded floor space'.
It was only after around seven days of hunger striking that the physical and mental condition of prisoners significantly worsened. During the Civil War, detainees at the Gormanston Camp, Co. Meath, organised their own medical service during a mass hunger strike. Prisoners were divided into hunger strikers and those who would provide care by nursing, making beds, and cleaning. One of the key duties of the quasi-medical staff was to ensure that a palatable water supply remained available. They supplied hunger strikers with boiling water mixed with salt and pepper (nicknamed 'soup' by the prisoners), a mixture believed to minimise the harmful effects of fasting. On the seventh day of this protest, IRA Captain (Dublin), Seán Prendergast, recalled that a number of men took to their beds exhausted and weak. He recollected his experiences of providing care as follows: Night duty was the worst of our ordeals. It was uncanny, weird and singularly unpleasant to sit at the fire … there to listen to the moanings and groaning of some of the men and to witness others as they tossed, turned and moved in their beds in troubled unsatisfying sleep or at other times being suddenly called to pay attention to one or more men, or requests for drinks of water … some would dream, openly and aloud, much of it and indeed much of their dream talk and sleep 'ramblings' concerned food, the lovely tasty and appetising meals they sometimes had, thought they had or would like to have … how such talk must have jarred their nerves and added to their other misery in not being able to sleep. By this stage, sustained food abstinence had resulted in dramatic calorie restriction which produced megalomaniac and persecutory delusions, auditory hallucinations, somatisation, dissociation, and confusion. As Seán suggested, it was at this stage that the emotional state of many of the prisoners deteriorated. In the initial days of their protest, hunger strikers had taken pride in their ability to use mind over matter. After seven days, they soon developed hallucinatory tendencies made worse by an inability to sleep.

Frank Gallagher recollected vivid hallucinations coupled with sleeplessness on his eleventh night. He recorded in his diary:
Must have raved all night. Thought I was stronger than that. But this sleeplessness is unbearable. But even an uncontrollable imagination darting in and out among dark thoughts, searching the closets of the mind, tearing up the very floorboards of the soul, could not find the idea of compromise-that gives me great strength. My weakness is physical, nervous only.
Frank's account suggests that the psychological changes that occurred during fasting in no way impaired his competence or produced severe mental deterioration. The changes that took place tended to be emotional (such as an increase in anger or anxiety). But he remained able to make a competent assessment of his situation. Gallagher also noted that his experiences were common among his fellow hunger strikers. On his thirteenth night, he recorded: Men are nearly mad now. Some of the other men, I know, but I am not mad. They are trying to make me mad. They are sending men to watch for me fear I should sleep. Telling the sentries to shout when I seem like sleeping. I am perspiring. Curious delusion that was. It has made me weak.
Evidently, Frank had begun to experience paranoia about the prison staff. Yet his accounts suggest that he remained relatively lucid, drifting in and out of delusions but mostly conscious that his paranoia was not real. Gallagher provided an account not of a gradual descent into mental illness but instead of constantly shifting emotional states. As he also wrote: 'I must fight all these mad thoughts when they come, the moment they come. Otherwise they will eventually crowd in and stay in and … Ugh! Better not think of that. It will come if we have much longer to lie here awake but it has not come yet.' At around ten days of hunger striking, many prisoners became bed bound. Glycogen stores were exhausted and muscle loss had ensued, particularly around the heart. Once 18 % of the body's weight had been lost, serious physical problems arose. The main disabling symptoms were faintness and dizziness. During the War of Independence, most prison doctors recommended discharge after ten days, and not normally after fifteen. Upon release, hunger strikers tended to be hospitalised. During his second hunger strike of March 1920, Mountjoy medical staff discharged Maurice Crowe to the Mater Hospital, Dublin, after ten days without food. Maurice kept his medical chart until at least the 1950s which included entries such as 'temperature 103. Condition: very weak'. He remained in hospital for a fortnight. In the following month, the Visiting Committee at Mountjoy reported that twenty-two prisoners had collapsed overnight after fasting for ten days. The Committee recommended early release. In 1923, after her tenth day of hunger striking, a doctor at Mountjoy reported that Mary MacSwiney (sister of Terence) was dangerously weak. She seemed to need food, stimulants, and special nursing if she was to remain alive. As the physical condition of prisoners gradually weakened and prison doctors came to fear death, hunger strikers in England were also transported by ambulance to nearby civilian hospitals. Edmond McGrath was moved to St. James Hospital, Highgate Hill, London, after fasting for nineteen days. After spending a number of days recuperating, the London branch of the Irish Self-Determination League paid for his fare home. Edward returned to Ireland by boat still feeling weak and sick.
Most prisoners who had been fasting for over a fortnight needed a careful recuperation period. However, rapid realimentation could be potentially dangerous as ingesting carbohydrates after fasting rapidly reverses many of the physiological processes of starvation, causing measurable weight gain and potentially acute oedema (an excessive build-up of fluids in the body). Heart problems were a further potential hazard. A sudden increase in fluid volume can precipitate heart failure. The quality of after-treatment available to recuperating prisoners varied, as did patient compliance. Many prisoners developed their own networks of care both inside and outside of the prison. By hunger striking, they came to understand what happens to the human body without food. For instance, they became progressively aware that eating needs to be resumed slowly after a hunger strike. When Mountjoy officials released the remainder of the prisoners on hunger strike following Thomas Ashe's death in 1917, the group recuperated in Mahony's Hotel, Dublin, where IRA (Wexford) officer, Paddy Brennan, instructed them not to consume solid food until advised to by the doctor called in to provide care. Nonetheless, William McNamara and Jack Madigan slipped out that night and drank numerous bottles of stout. Upon returning to the hotel in the early morning, they discovered that many of the released prisoners had surreptitiously eaten ham sandwiches, despite having been given advice to the contrary, and now appeared close to death.
Upon becoming hospitalised, prisoners found that doctors had varying levels of knowledge about how to recuperate hunger strikers. When IRA (Tipperary) Officer, Seán O'Carroll, was dispatched from Wormwood Scrubs to Highgate Hill Hospital, his doctor had no understanding of the effects of hunger striking, even though many of the prisoners understood the basic principles. Seán knew full well that he should not consume solid food for at least a week. Other prisoners fared less well. Fed with bread and butter while hospitalised, fifty recuperating patients began to suffer from violent heartburn and crippling stomach pain. Evidently, the informal networks of bodily knowledge accrued by prisoners were not necessarily shared by the doctors who attended them. However, it is important to note that some prisoners had more favourable experiences. On the twentieth day of his hunger strike, James Rankin was discharged to St. James Infirmary and put under the charge of two nurses, several layman orderlies, and a doctor. He later remembered receiving far better medical attention than he had in prison, and even at home in Ireland. His doctor performed a minor operation which James believed had saved his life. His local doctor in Ireland had been relatively indifferent to James's agonising stomach pains. The doctor at St. James Hospital also seemed more aware than his colleague at Highgate Hill that hunger strikers needed to resume eating at a moderate pace. Rankin recollected that the hospital staff were kind and thoughtful and allowed visitors to provide food. 'The doctor became alarmed', Rankin recalled, 'that we would overeat in our delicate state of health but he was need-lessly alarmed as he did not know the capabilities of an Irishman's stomach'. After a few weeks in the hospital, Rankin escaped after securing a day pass from a Scottish doctor.
It is worth noting that lower levels of medical care seem to have been provided for hunger strikers during and following the Civil War, a problem that encouraged prisoners at Gormanston Camp to fend for themselves. Seán Prendergast vividly remembered the fifteenth day of the mass hunger strike as: A critical moment in relation to the strike and effecting [sic] the general welfare of the men involved. It was a tense and anxious time for us who were attending to the wants of so many frail men. Some of them were barely hanging on to life by slender threads while even the strong and burly were showing signs of physical weakness under the strain and rigours of that long food fast. Our hut, other huts also, registered an uncommon number of bed patients. A few of the more robust were sticking it out more by will power and a strong governing spirit than any other known or unknown reason.
The leaders called off the Gormanston hunger strike on the sixteenth day. Seán partook in a slow process of helping the hunger strikers recover their health. Immediately after the strike had finished, the prisoners were given hot milk and advised not to consume coarse food. Light dishes were provided. Evidently, by the Civil War, hunger strikers were aware of the circumstances of bodily decay that result from prolonged fasting and the therapeutic strategies required for successful recovery. If anything, the existence of a quasi-medical service at Gormanston demonstrates the extent to which republicans informally understood the physical, psychological, and emotional implications of hunger striking even if many doctors remained less familiar with the physiological effects of self-starvation.
Notably, a shared understanding of fifteen days as a likely danger point fostered reluctance among some prisoners to hunger strike. IRA (Dublin) member, Stephen Keys, reluctantly went on strike at the Curragh Camp during the Civil War. Keys was determined not to abstain from food for any longer than fifteen days as a rumour had circulated around the camp that 'after fifteen days on hunger strike, you lived on the marrow of your bones and that you were likely to be a cripple for the rest of your life'. Keys recounted that up to 600 individuals broke the hunger strike on the fifteenth day. Although initially provided with small drops of Bovril, Keys witnessed one prisoner consuming large quantities of food from a swill bucket once the strike had been called off. The prisoner collapsed and was taken away on a stretcher. 'Two or three men happened to die from the same thing', recalled Keys, 'eating too much and not being able to get to hospital quick enough'.
Evidently, autobiographical evidence demonstrates that physical and emotional trauma was salient in the landscape of the revolutionary-period prison. The majority of republican prisoners who went on hunger strike were released between around ten and fifteen days as alarm rose about their decaying bodies. Initially, prison doctors believed that the rapid physical and psychological decay evident in the first few weeks of a hunger strike signalled imminent death. While doctors treated their patients with varying degrees of compassion, they deeply feared a controversial prison death. Notably, hunger strikers developed an intimate knowledge of what happens to their bodies while fasting. They came to understand the physical and emotional effects of starvation, recognised potential danger points, and accrued knowledge about recuperation. Informal networks of bodily knowledge were formed during the hunger strikes of this period that equalled-if not bettered-that possessed by doctors. It seems clear that the abandonment of force-feeding policies produced a range of bodily and emotional circumstances. Bodies decayed, prisoners hallucinated, and some struggled to recuperate. This was a situation that many doctors who supported force-feeding deeply wished to avoid. Patient autonomy was seen as important, yet doctors struggled to weigh the need to grant autonomy against the physical consequences of overseeing starvation.

Overseeing Death
Republican hunger strikes rarely lasted beyond fifteen days. Rather than let starvation run its course, prison doctors favoured early release. Politicians needed the backing of the British public for its campaign in Ireland which might have been hindered by an unfavourable prison death. Moreover, the government continued to believe that moderate Irish nationalists might be won over to the British cause until 1920. Michael Biggs suggests that a prisoner, by dying, would have signalled the deepness of his or her conviction in the justice of his cause, giving a convincing impression that the institutional circumstances that had resulted in a hunger strike were truly intolerable. However, in 1920, the government did allow some prisoners to starve to death. Nonetheless, the government remained determined not to continue caving in to hunger strikes. In August, a mass hunger strike commenced in Cork involving sixty IRA members, most of whom were being held without charge or trial. The British released or transferred most of the prisoners until only eleven were left. One prisoner, Terence MacSwiney, was transferred to Brixton Prison, London, where he continued his hunger strike. Terence had been arrested in Cork for possessing seditious documents and a cipher key. He died while on hunger strike, while two prisoners, Michael Fitzgerald and Joseph Murphy, died in Cork. These prisoners were allowed to starve as the government feared a mutiny among the disgruntled military and police in Cork. The group hunger strike in Cork eventually stopped in November at the request of Arthur Griffith, acting President of the Irish Republic. Although autobiographical material detailing the experiences of republican hunger striking beyond around twenty days does not exist (as hunger strikers had been released or were too weak to speak and write), insight into their physical, psychological, and emotional experiences can be gleaned from sources including Terence MacSwiney's medical reports, collated daily by the Home Office, and the Cork Examiner which printed regular interviews with visiting family members and friends.
The prolonged hunger strikes of 1920 made clear for the first time that human starvation could ensue for far longer than a fortnight. Indeed, these protests continued for over sixty days. The severity of physical and mental weakening, reported internationally in graphic detail, allowed images to circulate on the horrific impact of hunger striking on the human body that rivalled earlier depictions of force-feeding in their horror and intensity. The public spectacle that ensued led to international condemnation of British policies and generated deep concern over the welfare of Irish prisoners. Twenty days into the hunger strikes, the Cork Examiner ominously announced that 'the climax of the hunger strike in Cork Gaol is now at hand and will probably be reached in the next twenty-four hours'. However the hunger strikers did not die as quickly as expected. When Michael O'Reilly's sister visited him on the twenty-first day, she reported: 'My brother is very weak. His lips are cold. His hands are clammy, and his pulse is beating very slowly. He is much worse today. When he looked at me, with watery eyes, I was startled with his shrunken and haggard appearance.' Seán Hennessy's mother reported that he was suffering from blood poisoning in his heavily swollen leg and had lost his ability to speak. Two prisoners collapsed on the twenty-third day, raising concerns that their health would never be restored even if they were released. Seán Hennessy struggled to concentrate when his father read him extracts from a newspaper while Bourke complained of intense pains in his head and stomach. On the twenty-sixth day, Thomas Donovan collapsed, having begun to suffer from an abscess in the mouth creating fears that septic poisoning was developing. At this point, the prisoners began to object to visits being made by their doctors, arguing that if the position of his government was to let them die, then medical staff should let them die in peace. Sharing similar fears about the prospect of death, upon the twenty-sixth day of Terence MacSwiney's hunger strike, the Home Office requested daily reports on his health. The attending prison doctor visited Terence every two hours during working hours to compile his bulletins. By this stage, Terence was in a weak condition, but still conscious. He was dizzy and weak, and prone to sudden changes in his condition. He had begun to suffer from severe back and limb pains as well as constant dizziness.
But even after twenty-six days, the prisoners remained alive. After thirty-three days, the prisoners in Cork no longer had the strength to speak. They barely slept at night and were unable to recognise their visitors. Ex-County High Sherriff, Philip Harold Barry, attempted to intervene by sending a telegram to General Officer Commanding-in-Chief, Neville MacReady, in which he stated that 'it is very difficult to understand how the prisoners are alive at all', especially given that they had refused medical attention. Notably, MacReady observed that the prison doctors expressed deep sympathy with the men who were now being nursed by volunteer nuns. Fully aware that the prisoners and relatives might view them as agents of the British administration, medical staff made clear to the public that they were willing to step aside and allow neutral doctors to attend the patients if their families wished. Whereas a significant corpus of medical men had previously viewed force-feeding as unethical, it appears that prison doctors employed at Cork Jail felt similar unease about having to oversee self-starvation.
After around thirty-five days, the regional press stopped discussing death as imminent. Instead, they began to comment on the miraculous longevity of the prisoners. 'In the history of hunger strikers', reported the Cork Examiner, 'this is presumably a record'. From here on, journalists began to valorise the perseverance of the hunger strikers in battling both the British government and human nature for the moral cause of securing an independent Ireland. As Murphy argues, the press told the stories of their deaths in ways that offered solace and admiration rather than condemnation. The Cork Examiner wrote: The hunger strikers in Cork and Brixton still maintain their struggle with death, and wonder grows at their marvellous endurance and sets precedent at nought. Sustained by unswerving faith in the justice of their cause, these exhausted youths and men continue to make their protest, even though they are convinced that it entails the ultimate sacrifice.
After enduring thirty-seven days on hunger strike, the Home Office raised the number of reports compiled daily on Terence MacSwiney's health to six. Their content differed little until the fiftieth day of Terence's fast. Each day, the attending doctor repetitively reported that the former Lord Mayor remained conscious with his condition having changed little since the issuing of the previous bulletin. Bereft of gruesome details of physical decay to report on, a journalistic rhetoric evolved that helped to transform the hunger strike into something miraculous, as a psychological victory of endurance and a spiritual triumph of mind over matter.
In October 1920, a number of rumours (or, as James Vernon describes them, carefully calibrated leaks) emerged that Terence MacSwiney was being secretly supplied with food, a claim intended to demystify the hunger striker's lengthy fast. The medical profession quickly rebutted this suggestion. In October, the Medical Press and Circular rejected insinuations that individuals who abstained from food for longer than a month were surreptitiously consuming food by scouring the medical literature to examine the careers of professional fasters who had survived without food for up to fifty days. 'An energetic and determined will', explained the Medical Press and Circular, 'whether it be sane or insane, is the strongest weapon man can oppose to inanition'. Similar suspicion about prison activities also emerged in Ireland. On the forty-eighth day of the Cork Gaol hunger strikes, two doctors (Drs Learson and Battiscombe) agreed to be interviewed by the Cork Examiner and expressed their amazement that eleven hunger strikers in Cork Prison remained both alive and semi-conscious. The doctors took care to ridicule rumours that the nuns caring for the prisoners were disguised Government nurses.
It was on the fiftieth day of hunger striking that Terence MacSwiney's physical condition rapidly deteriorated as he entered into a state of complete exhaustion. Six days later, his doctor wrote, 'it causes him great distress to say even a single word. He tries to whisper something, gasps, becomes very exhausted, and then cannot continue.' Between days sixty-seven and seventy-four of his hunger strike, Terence developed scurvy, although his wife refused to feed him the recommended lime and orange juice. The prison doctor also reported that Terence's mental condition had worsened, noting that he was suffering from a violent delirium caused by prison officials having placed meat juice in his mouth. "They have tricked me and I did not know it", he exclaimed, "take it away! Take it away!" Terence MacSwiney died on 25 October 1920 after enduring a seventy-four-day hunger strike. His treatment in England differed profoundly from his fellow prisoners in Cork where prison doctors had shown greater respect for the wishes of the prisoners and their families. Michael Fitzgerald died in Cork Gaol on 17 October 1920 after enduring a hunger strike of sixty-seven days. On 25 October, a further untried prisoner, James Murphy, died after a fast of seventy-six days, on the very same day as Terence MacSwiney.
To some surprise, the longevity of these hunger strikes firmly demonstrated that humans could potentially survive without consuming food for over two months, even in unfavourable prison conditions. This revelation added important new contours to ongoing debates on hunger strike management. Nonetheless in the public eye, allowing prisoners to slowly starve over protracted periods of time was deeply objectionable. Self-starvation was widely understood only as a quasi-suicide, as a necessary protest predicated, in this instance, to add weight to the legitimacy of the republican cause. It could still be construed as a form of violence being used by a government who had alternative options available such as recommending early release, granting concessions, or bringing internees to trial. In its eagerness to avoid a further controversial death associated with force-feeding, the British government helped to create a new, perhaps more dangerous, type of Irish martyr, one who could be construed as a victim of British policies of bodily repression in the way that Thomas Ashe had been valorised as an individual with a sound moral cause suffering a self-imposed atonement for a broader spiritual and political cause: Irish independence.

Conclusion
Between 1917 and 1923, hunger strike management policies in Ireland rapidly adjusted. Although the Home Office refused to formally acknowledge that force-feeding was potentially life-threatening, even despite the irrefutable evidence of Thomas Ashe's death, it gradually abandoned the practice. The War of Independence and Civil War placed new pressures on prison medical staff as republican prisoners mobilised to undertake a series of (often successful) hunger strikes as part of their attempt to disrupt key institutions of the British administration. Although the Home Office officially stated that it would no longer release prisoners prematurely under the Cat and Mouse Act, in practice the vast majority of hunger strikers were released between around ten and fifteen days of fasting. Throughout much of the period of conflict, prison doctors believed that prisoners would not be able to endure fasting for any longer. Hunger strikers displayed a range of physical, emotional, and psychological conditions, causing considerable alarm among prison medical staff who tended to recommend early release. The hunger strikes of 1920 decisively demonstrated that humans could in fact sometimes remain alive without food for periods of over two months. Yet rather than easing the pressure on prison officials to either force-feed or support early release, the graphic and wellpublicised details of long-term starvation aided the cause of the rebellious prisoners, attracting widespread sympathy even among those not naturally allied to the militant cause.
It seems clear that policies of permitting self-starvation place pressure on prison medical staff, albeit in different ways than force-feeding. Self-starvation disrupts the normal workings of prisons, leaving medical staff bereft of their normal technologies of discipline and punishment and granting prisoners bodily autonomy in a system deliberately curtailed to curtail personal independence. Although force-feeding has always been associated with brutality and torture, it fulfils the idea that doctors have a medical duty to preserve health and save lives. In the absence of forcefeeding policies, doctors are obliged to stand back and watch groups of prisoners mutilate and damage their own bodies, sometimes irreparably. They find themselves in a situation where healthy, young politicised prisoners inflict harm upon themselves and refuse medical intervention. It is common practice today for hunger strikers to be left to their own devices (with Guantánamo providing an important exception). Yet doing so is physically and emotionally traumatic for both prisoners and doctors, a problem that goes some way towards explaining why many prison doctors, when faced with hunger strikers, might feel a need to provide food, even if this does involve resorting to a painful, degrading procedure.

Footnotes
For discussion, see Rachels James. Active and Passive Euthanasia. In: Jecker Nancy S, Jonsen Albert R, Pearlman Robert A, editors.
Bioethics: An