Alexander’s Fever
A Historical CPC

Philip A. Mackowiak, M.D.
Director, Medical Care VA Maryland Healthcare System
Professor and Vice Chairman, Dept. of Medicine
University of Maryland School of Medicine
Innominate Society T. Cook Smith Lecture
Edited by John J. Schwab, M.D


          Alexander the Great claimed to be the son of the King of the Gods, and yet, four months shy of his thirty-third birthday he was dead. Some say he was poisoned-a victim of the many powerful enemies he had created during his twelve years and eight months in power. Others say he drank himself to death. He was drunk when he scorched the palace of the Persian monarchs in 330 B.C. and when he murdered his friend, Clitus, in 328 B.C. Still others say he just gave up. After the death of his bosom companion, Hephaestion, he seemed to care little for that fragile thread the Fate, Atropos, would sever in less than a year.

Alexander’s illness began in the summer or 323.  He had been agitated since his recent return from conquering India, and though characteristically temperate, he had been drinking heavily since Hephaestion’s death. By some accounts, he had caroused almost continuously for seven months. His final illness began after one of his drinking marathons at a dinner hosted by Medius. The details of the onset of his illness are sketchy, but most likely it began with high fever and abdominal pain.

On the first day of illness, he bathed and then slept in the bathing room because of his fever. But, on the next day, he felt well enough to play dice with Medius, and he then bathed again, sacrificed, and ate a hearty dinner. That night his fever returned and increased in intensity during the next several days. Initially, he was able to discuss navel strategy for the upcoming Arabian campaign with his Admiral, Nearchus. However, by the fourth day of illness, his strength began to ebb, and by the seventh day, his condition was so severe that he had to be carried from his bed and assisted with his daily sacrifices. Guards were posted around him. Next, he was taken back to the palace, but there, he slept little because of his fever and soon was unable to speak. His troops, fearing the worst, demanded an audience, and as they filed by in silent review on the tenth day of the illness, he struggled to raise his head but could do little more than follow with his eyes as each individual passed by. Shortly thereafter, on the eleventh day of illness, he died. In the confusion that followed, six more days elapsed before the embalmers reached him. Some say that they found the body uncorrupted despite the summer heat. They prepared it with such skill that on viewing the body nearly three centuries later; Caesar Augustus is reported to have remarked on its beauty.

In life, as in death, Alexander had been extraordinary. He had great personal beauty and charm, an incomparable power of endurance, and a remarkable intellect. However, he had used his body savagely in the relentless pursuit of fame. He was wounded at least ten times during his conquests. At his great victory at Issus, his shank was so badly shattered by an arrow that splinters of bone had to be removed from the wound. On another occasion, he received a blow to the nape of the neck so severe that he had difficulty seeing for some time thereafter. At Granicus, Spithridates hit him with a battle-ax hard enough to shear the plumes from his helmet and graze the hair on his head. Had Clitus not intervened, Spithridates would have dispatched him with the next blow of his axe. At Multan, he received his most serious wound. During the siege of that Mallian town in 326, an arrow penetrated his cuirass and went between his ribs near his heart. It was embedded in bone and was extracted only with considerable difficulty. Blood mixed with air blew from the wound with each breath, indicating that the lung had been punctured. Months passed before he recovered sufficiently to continue the journey home.

Furthermore, disease, like battle wounds, was Alexander’s constant companion. For nearly a decade, he had driven his men and himself through some of the most pestilential areas of the globe. There is little doubt that he contracted malaria during his Eastern campaign or that his army suffered constantly from it. At tarsus, in 333, he was incapacitated by illness for two months. Darius mistakenly attributed is inactivity during that illness to cowardice but, in all likelihood, malaria was the cause.

Alexander came from hearty stock. Although he later claimed to be the son of Zeus, Philip of Macedon was his father. Philip was gifted physically and mentally and, he like his son was a mortal. Alexander’s mother, Olympias, was alive and well at the time of his terminal illness, as was his younger sister, Cleopatra. His older brother, Arrhidaeus, was severely retarded, most likely from birth, but some say that Olympias gave him drugs that ruined his health and reduced his understanding.

Alexander was bisexual. He had three wives, the newest of whom was pregnant with his only child. Also, he had at least two male partners, especially Hephaeston, who was his oldest friend, lover, and most trusted commander. He is reported to have had a sexual relationship with the Persian eunuch, Bagoas, who had formerly served Darius. Nevertheless, prior to his return from India to Persia, Alexander had indulged in the bodily pleasures quite moderately and generally was temperate in regard to his diet and almost everything except his love of glory and of knowledge, both of which he pursued indulgently and excessively.

Although numerous conditions- often poisoning, malaria, or pancreatitis- have been postulated to be the cause of his final illness, his symptoms and signs, in particular, the progressive weakness abdominal pain, aphonia, and post-mortem incorruptibility, point to the diagnosis being typhoid fever complicated by ascending paralysis. Alexander’s oldest and closest friend, Hephaeston, also probably died of typhoid fever. Possibly, they were infected from a common source.

Initially, Alexander exhibited the classic symptoms and signs of typhoid fever- remitting fever that climbed in stair-stem fashion to continuous high fever, along with abdominal pain, malaise, and generalized weakness that progressed in a pattern suggestive of ascending paralysis. At first, the weakness was manifested by an inability to walk and then to perform the usual daily sacrifices. Ultimately, his power of speech failed as the higher motor areas became progressively more involved in the ascending paralysis.

If Alexander’s corpse was surprisingly fresh when the embalmers arrived, as is reported, even though considerable time had elapsed since he died, tow explanations are plausible. Either the story is apocryphal or Alexander died later than was believed. Possibly, typhoid-induced Landry- Guillain-Barre syndrome created the appearance of death for a number of days prior to the actual event. If so, the robust Alexander of little more than a week earlier might have enabled the apparently dead Alexander to teeter at the very precipice of death without food or water for several days before he finally succumbed.

If Alexander had survived his fatal attack of typhoid fever, we can only wonder how much longer he might have lived or what other worlds he might have conquered. In many respects, what is remarkable is not that he died so young, but that he had survived so long despite extended periods of extreme privation, exposure to rampant communicable diseases, heavy alcohol consumption in his later years, and the intense court intrigues that often had lead to the “death of kings".