Alexander the Great: The Death of a Legend

This is a report I wrote on one of history’s most famous figures. While scholars still debate over whether or not Alexander was heterosexual, homosexual or bisexual, he still left a lasting impression on the Western world. I think, personally speaking, that it’s probable that he was homosexual in orientation, or at the very least bisexual, given his deep relationship with Hephaestion (there are hints that their relationship was sexual at some points in the primary sources). I wrote a paper regarding the circumstances behind his death, and in defense of a relatively new theory as to how he died. Enjoy!

The death of Alexander the Great marked the end of one of the most famous figures in history. Alexander the Great brought Greek culture and language thousands of miles from its origins on the Greek mainland, brought down the Persian empire and revolutionized military science. At the young age of 32, he fell ill and died. It is still a mystery as to his exact cause of death. Many theories have been proposed, ranging from deliberate poisoning, to malaria. Yet of all the illnesses that have been proposed, there is one that few scholars or doctors ever considered until just recently. Given his symptoms, campaigns and lifestyle choices, there is a good possibility that Alexander the Great died from the infamous West Nile virus.
The best way to chart the path of Alexander’s illness is to begin with all of the surrounding factors that may have affected Alexander’s health just before his death. Alexander was known to engage in wild drinking parties, and has even been described by some scholars as suffering from alcoholism (Romm, p. 168). During his time in India, Alexander was seriously wounded in the chest and, based on the description of the wound as spurting “blood and breath,” (Romm, p. 142) suffered a punctured lung, a wound that he was lucky to have survived. It is reasonable to suggest that Alexander’s mental state was also less than satisfactory at the time of his death, given the relatively recent death of his lifelong friend, and possible lover, Hephaestion.
Next, one must consider all of Alexander’s known symptoms. Alexander’s symptoms have been variously described as an escalating high fever, thirst, loss of appetite, abdominal pain, thirst, early back-pain, weakness with a few periods of energy, delirium, loss of speech, paralysis and finally death (Marr, p. 1600). Unfortunately, it is difficult to ascertain the accuracy of the primary and secondary sources that give us Alexander’s symptoms, which occurred over the course of approximately 11-13 days. Arrian tells us that on the first night of Alexander’s illness that he had been drinking heavily when he came down with a fever. On the next day he was taken out on his bed to perform sacrifices to the gods and to give orders to his men, but spent most of the day sleeping. On the third day he did the same, in addition to eating some food, with the fever persisting. On the fourth day he continued to give orders, and on the fifth day he was still relatively well but was now in a constant fever. During that evening his condition worsened, and by the sixth day he was becoming increasingly weakened. His condition remained unchanged for the next two days. By the ninth day he was seriously ill and lost his ability to speak. His high fever persisted until his death about 2 days later. Like Arrian, Plutarch tells us that Alexander lost his ability to speak toward the last few days of his life. He specifically denies that Alexander had any abdominal or back pains, claiming that such assertions by other authors were just melodramatic fabrications. Plutarch also mentions that the fever was very high. Aristobulus maintains that Alexander’s first symptoms were fever, extreme thirst and delirium. Admittedly, it is difficult to tell whose version of Alexander’s final days is the most accurate, but for the purposes of this paper all symptoms mentioned by primary and secondary sources will be considered in formulating a hypothesis as to what killed Alexander. There are many theories as to what specific illness or substance could have caused Alexander to develop these symptoms.
Some scholars and doctors have proposed that Alexander may have died due to poison. It should first be noted that the majority of poisonous substances do not cause fevers . Most of the relatively few poisons that can cause fevers were not available in antiquity. The very few that were, include plant salicylates, ergot mycotoxins and alkaloids like strychnine. Paul Cartledge proposed that a small dose of strychnine, a naturally occurring substance known in antiquity and still used today, may have been used to kill Alexander (Cartledge, p. 215). Strychnine has been used in medicine since ancient times, often as a stimulant, and is indigenous to parts of India. Its effects were well known and reflected in the Latin scientific name of the tree that strychnine comes from, strychnos nux vomica. This roughly translates as “nightshade nut that causes vomiting,” referring to its potent emetic properties. While Alexander undoubtedly had his enemies, Cartledge’s assertion is almost totally baseless. First, strychnine is extremely bitter (Engels, p. 224). It is very unlikely that it could have been given easily to Alexander without him noticing it. Even if it had somehow been given to him, or if he had perhaps ingested or inhaled it accidentally, he would not have been able to lay down in bed easily, since strychnine causes agonizing muscular spasms and convulsions. Also, even if the strychnine had been given to Alexander in extremely small doses over a long period of time, the subsequent fever would have been very mild (perhaps even close to a normal temperature), certainly not like the high fever described by primary sources. Also, the symptoms would probably not have come on as suddenly as they did in Alexander’s case. Finally, a fever caused by the aforementioned salicylates and ergot mycotoxins would not be a high, constant fever like the one Alexander had (Marr, p. 1599).
Arsenic has also been suggested as a possible poison used to kill Alexander. It can be rendered practically tasteless, making it easy to slip into food or liquids. It would account for Alexander’s weakness and paralysis, and his supposed gastric symptoms, but it must be ruled out for several reasons. Arsenic poisoning does not cause fever. Short-term arsenic poisoning would be fatal within a day or two, and arsenic would cause much more violent and unusual symptoms than the ones described. Finally, arsenic was apparently not precisely isolated until 1250 CE, and it is thus unlikely that it would have been used in antiquity as a poison (Lederer, p. 1).
Some drugs have been known to cause fevers, but like poisons, they are also relatively few and are ones that were unknown in antiquity, such as chemotherapy drugs, antibiotics, antipsychotics, etc. Opium withdrawal can cause fever and it was prevalent in the Orient, as it still is, but none of Alexander’s other symptoms suggest opium withdrawal (Beers, p. 594).
Food poisoning has also been considered as a possible cause of death. Salmonella, botulism and other forms of food poisoning are all caused by either infectious agents or the toxins produced by them. While food poisoning can cause fevers and would not have been a surprising occurrence in antiquity, it would not have been responsible for some of Alexander’s other symptoms. Salmonella symptoms do not normally last for more than 3-7 days, and the symptoms are usually confined to the gastrointestinal tract (i.e. vomiting, etc.). E. coli food poisoning does not normally cause a high fever. Botulism could account for Alexander’s gastric symptoms and weakness, but its neurological symptoms are usually limited to muscle weakness and breathing difficulties, not the delirium that Alexander was said to have experienced. In fact, the victims of botulism poisoning are generally quite lucid. Also, botulism does not usually cause fever. There are literally dozens of other forms of food poisoning, but most are generally characterized by vomiting, diarrhea and other gastric symptoms rather than the high fever and neurological symptoms noted by primary sources.
On the first night of his illness, Alexander was drinking heavily. It is thus not unreasonable to ask whether his alcohol consumption had anything to do with his illness. Although some of Alexander’s symptoms were similar to that of an alcohol overdose, fever and abdominal pain are not among the symptoms of such an overdose. Dr. Charalambos Sbarounis, M.D. suggested alcohol-induced pancreatitis (Sbarounis, p. 295-296), given Alexander’s abdominal pain, back pain, high fever, thirst and mental deterioration. Two similar theories put forth include the possibility of similar alcohol-induced diseases, specifically hepatitis and ruptured stomach ulcers (Mackowiak, p. 69-70). Another theory suggests the possibility that Alexander drank so much that he actually ruptured his esophagus (Battersby, p. 86). While these four theories are quite plausible considering Alexander’s lifestyle of heavy drinking, they generally fail to account for Alexander’s severe weakness, loss of speech and his eventual paralysis (Mackowiak, p. 70). Also, they do not account for the unusual symptom of Alexander’s brief period of energy. In fact, Alexander was well enough in the beginning stages of his illness to bathe, talk to his generals and perform sacrifices to the gods (Romm, p. 169). These four illnesses tend to cause excruciating pain relatively quickly, especially perforated stomach ulcers and esophageal ruptures , and they would have left Alexander unable to function in his day-to-day duties, which he seems to have done at least in the beginning.
However, given the presence of a fever, it can be assumed that Alexander indeed suffered from some type of infection. There were plenty of illnesses in the Middle East that could have afflicted Alexander. Among them are malaria, typhoid fever and others.
Malaria has been proposed as a possible cause of death for Alexander. It was well known in antiquity, and often referred to as pyretos , the Greek word for fever (Borza 1979, p. 102). It was feared by soldiers who had to march through marshy areas, where the female mosquitoes that transmit the disease were prevalent. Several years prior to his fatal disease Alexander had a mild illness characterized by a fever, cramps and insomnia (Romm, p. 47). It is possible that this illness could have been a type of malaria caused by plasmodium malariae, which can actually remain dormant in the bloodstream for years before reactivating (Beers, p. 1031). The stress of Hephaestion’s death, repeated injuries and drinking parties could have been more than enough to bring the disease out of dormancy. Malaria is consistent with some of Alexander’s symptoms except for abdominal pain, which is not a normal feature of malaria (Borza 2000, p. 25). Although some forms of malaria can cause a continuous fever, Alexander’s travel history makes it probable that he would have been exposed to a type of malaria called plasmodium falciparum. This is important because one of the distinguishing features of this type of malaria is the unusual fever pattern. With this type of malaria, the fever actually comes and goes in recognizable cycles. Alexander’s persistent high fever reduces, although not completely eliminates, the probability of malaria as being his cause of death.
One theory accepted by many scholars and doctors is that Alexander perished from typhoid fever. The evidence for this assertion is quite persuasive. Typhoid fever could explain most if not all of Alexander’s symptoms, but one problem with typhoid fever as being a cause of death is the timing of the symptoms. In the cases where typhoid fever has proven fatal , death has usually occurred by the end of the second week, but the neurological signs (such as Alexander’s delirium and eventual paralysis) generally occurred in those who managed to survive after three weeks (Marr, p. 1600). Assuming that the primary sources were correct in noting how long it took for Alexander to die, the points at which the symptoms manifested themselves during the illness seem inconsistent with a normal case of typhoid fever. The neurological symptoms occurred too early.
While typhoid fever is a stronger possibility than malaria, there is one other disease that doctors and scholars never considered until recently. Before the late 1990s, scholars and doctors usually paid little attention to an interesting event recorded by Plutarch. Prior to entering Babylon, Plutarch reports that Alexander saw a flock of crows or ravens attacking each other and then dropping dead in front of him. Although any flock of birds could have demonstrated this behavior for a variety of reasons, the fact that the birds were ravens or crows makes one explanation for their behavior stand out. This behavior as documented by Plutarch is exactly how crows and ravens infected with the West Nile virus would behave (crows and ravens are more susceptible to the West Nile virus than most other types of birds).
One cannot be entirely sure that Plutarch did not add this incident for dramatic effect, but it would fit in perfectly with an outbreak of the West Nile virus in Babylon similar to the one that occurred in the United States in 1999. Several mosquito species in present-day Iraq, where Alexander became ill, have been suspected of spreading this virus, and these mosquitoes tend to become active in the spring when the Tigris and Euphrates rivers flood. This would make Babylon’s location between the two rivers the perfect area for West Nile virus to appear. The West Nile virus, like many others, comes and goes in mammals over time due to fluctuations in the number of mosquitoes and changes in the virus that can make it more or less transmissible to animals and humans. Over 80% of people infected with West Nile virus never show any symptoms at all, with another 19% showing only mild, flu-like symptoms that end within a week or less (Huhn, p. 656). This shows how outbreaks of this virus can affect thousands of people, yet relatively few actually become seriously ill (Tsai, p. 767). This could explain why no such illness was reported among Alexander’s soldiers or any of the residents of Babylon. Even if no one else in Babylon had been infected with the West Nile virus, that does not necessarily mean that Alexander alone could not have become infected. In fact, it is more typical of the West Nile virus to infect a small group of people, or even a single person, at first rather than large groups of people all at once. Typhoid fever, malaria and other diseases would probably have affected large numbers of Alexander’s men and the Babylonians in general, and we have no record of any such outbreaks of illness at the time of Alexander’s death. In less than 1% of infected individuals, usually the elderly, young children and those with compromised immune systems, the virus can cause deadly brain inflammation (encephalitis). This is specifically what Alexander may have, in fact, died from, since he showed neurological signs (i.e. loss of speech, delirium, etc.) in addition to all of the other symptoms of West Nile virus. Although acute pancreatitis was previously ruled out in and of itself, some victims of West Nile virus can actually develop pancreatitis in addition to other complications (Perelman, p. 1150). Therefore, Alexander could have died from a combination of both West Nile encephalitis and pancreatitis.
The West Nile virus, as well as resulting cases of encephalitis, can cause a high fever (which could easily result in the thirst Aristobolus describes), loss of appetite, sudden body pains (such as a headache), disorientation or delirium, back aches, weakness and paralysis. In fatal cases, the time between the onset of symptoms and death varies widely, from several days to several weeks (Huhn, p. 657). The symptoms of West Nile encephalitis match Alexander’s symptoms relatively well.
In an attempt to discredit the theory that Alexander died from West Nile virus, Dr. Mackowiak points out that the West Nile virus is rarely fatal in otherwise healthy individuals (Mackowiak, p. 72). While this is true, Mackowiak makes the false assumption that Alexander was a perfectly healthy individual at the time. Alexander had a habit of consuming large quantities of alcohol, and had in fact done so right before his illness occurred. Recent clinical studies have suggested that heavy consumption of alcohol suppresses the immune system significantly, predisposing one to develop various infections that one might not normally develop (Roselle, p. 1-6). It would also mean that Alexander, once he became infected, would have a much more difficult time fighting the virus. One must also remember that Alexander had been constantly fighting for years, and that his occupation as king must have been very stressful indeed. The terrible shock of Hephaestion’s death should also be remembered, since the loss of a life partner or a spouse (whether or not Alexander and Hephaestion’s relationship was ever homosexual, E. N. Borza asserts that Hephaestion essentially functioned as a de facto “spouse” to Alexander) can have deleterious effects on one’s physical health (Borza 2000, p. 27). Alexander’s personal habits, his job and his personal life ensured that he was by no means a healthy young man when he became ill.
Scholars and medical doctors have spent years trying to discern exactly what killed Alexander. One can never be sure that our primary sources accurately documented Alexander’s symptoms, or the amount of time it took for him to die. However, if the primary sources were in fact accurate, then a good case can be made that Alexander died from encephalitis caused by the West Nile virus. It is interesting to consider that Alexander the Great, who defeated powerful enemies during his life, may have lost his final battle at the hands of a microscopic enemy.

BIBLIOGRAPHY

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