Signs of death ============== * Heidi Marx Nearly one year to the day after my exhusband died from Stage 4 lung cancer, I received the proofs of my coauthored sourcebook on ancient medicine. I read line by line what I’d written a couple of years prior under the difficult circumstances of a pandemic, not knowing that things could and would get so much harder. I found myself raw and on the verge of tears at many points while reading about the suffering, illness, pain, and loss of ancient humans. But what moved me to tears came at the end, namely, when I read our final section on geriatrics and signs of death. We wrote, “As life came to a close, there were a number of bodily signs that announced one’s impending death.” The specific signs that the Hippocratic author of *Prognosis* tells his readers to be on the lookout for are “sunken eyes, cheeks and temples; the nose taking on a sharp and pronounced appearance; the ears becoming cold and the earlobes drooping; the skin on the face becoming dry, stretched, and hardened; and the complexion becoming pale and dusky.”1 Check, check, and check. Google Photos perversely sends me these precise images with cheery titles like “Walk down memory lane” or “Remember when” or “One year ago today.” Little sucker punches in the stomach the first few times it happened. Ancient physicians paid attention to changes in pulse and urine, to the way a patient slept, “whether with eyes partially opened and mouth agape, with the legs curled up, whether fitfully, and so forth.” We lived this as well. The palliative nurse had come earlier that day to help with changing and washing and administering morphine. When we were alone, she told me quietly and calmly that she could barely feel a pulse, and that my exhusband likely wouldn’t live more than a few hours. I didn’t quite grasp what she said. It only sank in later, when she turned out to be right. The medical texts I study also talk about changes in breathing. That last night, thinking we were in for weeks of palliative care at home, I volunteered for the intimate parts of this regimen, and my son and I slept fitfully on a leaky air mattress on the floor of the same room. Then I heard it. A change in his breathing. I called another family member in, not knowing what to do. We decided to give him oxygen, the soft hiss of the tank comforting us with the thought that he could breathe easier now. When I left to make tea, he died with only our sleeping son as his companion. In less time than it took to boil a kettle, he drew his last breaths. We had written that ancient physicians watched for signs of death to tell them when to withdraw care. Now, having lived through the last moments of my exhusband’s life, other explanations seem more apt to me. Many people, like I was before my exhusband died, are unacquainted with the signs of impending death. But it is likely that many members of an ancient household, especially women and servants, did know the signs of death intimately. Those people wouldn’t have needed Hippocrates and Galen to tell them when someone was about to die. But the male apprentices, students, and educated readers of these ancient physicians needed to be told precisely because they were the least likely members of an ancient household to have seen it. My personal experience of a loved one’s death allowed me to think more clearly about the death-bed reality of my fellow human beings in the ancient world. The author of *Prognosis* likely felt that nascent physicians needed to know at least as much as householders. Physicians in antiquity needed to know when to step away in order to avoid torturing the dying with emetics, enemas, baths, venesection, cautery, cuppings, and concoctions (or the modern farce of connecting a loved one to an oxygen tank in his last moments) and to leave the dying in peace. I had more in common with ancient physicians’ apprentices than family members present at the death bed of a loved one in the past. Like ancient physicians in training, we “moderns” need to know these things, the signs of death. Many of us experience how life begins, but few of us know how life ends until it does, and we are at a loss. We have great fear of death and dying in the modern Western world because we rarely experience the final moments of a life. And when we do, we find out that we’re not very good at it; there are so many ways to get it wrong. I wish I’d been there in my ex-husband’s last moments, without the hiss of an oxygen tank, instead lighting a candle, and singing or saying a prayer. There will be future opportunities to do better at being present with the dying. I live with daily awareness that many of the people I love are growing not just older but old. Being present at the end is a life-changing experience, and that cannot have been lost on ancient physicians and medical writers. Humans do the most amazing things with their dying bodies. Although a mere skeleton and in excruciating and unrelenting pain when unmedicated, my son’s father waited for weeks until we could visit, and then he hung on to get home to his brother’s house and away from the constant beeping and chiming of hospital monitors, to the quiet. He waited just a few more moments to find peace among his brothers, sisters, son, and strangely enough, generously enough, me. In spite of my speeches to students about modern hubris and ancient wisdom, I didn’t pay attention to the ancient voices that told me exactly how people die. Maybe they would also have told me how to say goodbye, how to send a soul on its way, how to wash and care for what remains, and how to start the long process of grief and mourning that comes next. ## Footnotes * This article has been peer reviewed. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/) ## Reference 1. Upson-Saia K, Marx H, Secord J. Medicine, health, and healing in the ancient Mediterranean (500 BCE–600 CE): a sourcebook. Berkeley (CA): University of California Press;2023:378.