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Death of a Great Emperor: A Medical Enigma.  

Dr Sampurna Roy MD          


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It was a beautiful Saturday afternoon. I switched on my favourite music and settled down to update some of my old posts on infectious diseases. Suddenly Dad walked in with a set of articles and said "read these and write a short story ".  Oh no Dad I have to.... He smiled and said  "this is also about infectious disease" and walked out.  Now I don't have a choice.


Death of a Great Emperor: A Medical Enigma.


         Alexander- Acropolis Museum-Athens (courtesy -wikimedia.commons)

Alexander the great (356-323 BC) has fascinated men ever since he lived over 2000 years ago.

He became king of Macedonia in Greece before he was 20 and in 12 years he conquered great kingdoms without ever losing a battle.

He was a great leader in every sense of the word.


 Surrender of the mighty Paurava king Porus, in 326 BC to Sikander (Alexander, King of Macedon)

I will briefly mention about his famous battle in India.

In 327 BC he led his army over River Indus now known as River Jhelum and invaded Punjab.

Ruler of Punjab King Porus fought bravely but was defeated and taken prisoner. Gracious Alexander the Great asked Porus how he wished to be treated. "Treat me, Alexander, as you would treat a King" replied Porus. Alexander asked him to be more precise. Porus repeated  "Everything is contained in this one request." Alexander was so impressed by his dignified answer that he not only returned his entire kingdom but enlarged his territory by adding more lands to the East. Porus and Alexander became great friends and allies.

Alexander died at the age of 32 when he returned to Babylon (present-day Baghdad) from the Indian subcontinent in 323 BC. 

According to medical literature he had a clinical history of fever for 2 weeks  associated with chills, acute abdominal and substernal pain, back pain at the onset fever, excessive thirst, tremor, stiffness of neck, progressive inability to walk, delirium and flaccid paralysis. Finally he fell into a coma and died.

There has been much speculation about his actual cause of death.

Possible explanations for his death have included alcoholic liver disease, acute pancreatitis  secondary to heavy alcohol consumption and a very rich meal or strychnine poisoning. There is little data to support these conditions as the cause of his death. Death due to poisoning was suggested by many scholars. It was finally ruled out as very few poison cause febrile illness and these were not available during Alexander’s time.

Some authors have considered his death due to malaria, typhoid fever , Schistosoma haematobium infection (Schistosomiasis) which were common in ancient Babylon.

Neurological symptoms in Typhoid occur on the 3rd week. Other symptoms of typhoid include cough, diarrhea, “rose spots,” epistaxis, and bloody stool. None of these symptoms were mentioned by Plutarch in his biography about Alexander.

Dark urine, (blackwater fever) or intermittent fevers noted in Malaria were not reported. Most malaria in Iraq is due to Plasmodium vivax. If Alexander had malaria it would have been due to Plasmodium falciparum. The  dramatic pattern of fever noted in Plasmodium Falciparum was absent.

Symptoms like low grade fever and pruritic swellings, present in Schistosoma haematobium infection were not reported in Alexander’s case.

Best explanation was given by Marr JS and Calisher CH in their article "Alexander the Great and West Nile Virus Encephalitis"

They suggested Alexander the Great died due to West Nile Encephalopathy. (West Nile Virus disease)

According to Greek biographer Plutarch, as Alexander entered Babylon a flock of raven showed unusual behavior and finally died at his feet. This provided the clue to his death. The ravens may have died due to West Nile virus infection.

Finally, from a pathologist's point of view I would say just one autopsy would have answered all the questions. Without the actual body of Alexander the Great the cause of death will continue to be a medical enigma.

There is a lesson in every story.The differential diagnosis discussed in various medical literature will be a great learning experience for clinicians dealing with exotic infectious diseases in foreign countries.


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Dr  Sampurna Roy  MD

Consultant Histopathologist (Kolkata - India)







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