Alexander III of Macedon spent eleven years taking an empire that ran from Greece to the Punjab, and in the spring of 323 BC he was back in Babylon planning the next campaign, a sea and land expedition to Arabia. In June, a few weeks before his 33rd birthday, he fell ill after a night of drinking and was dead within about twelve days. A Babylonian astronomical diary, a clay tablet now in the British Museum, notes the death of the king; scholars working from it usually put the date at 10 or June 11. He named no clear heir, his generals fought over the empire for forty years, and the question of what killed him has never been settled.
What happened
The fullest account comes from the so-called Royal Diaries, a court journal quoted by the Greek historian Arrian and by Plutarch some four centuries later. In Arrian’s version Alexander drank late with his friends, accepted an invitation to keep drinking with his companion Medius of Larissa, and went to bed already feverish. For several days he bathed, slept, was carried out on a litter to perform the daily sacrifices and kept giving orders to his admiral Nearchus about the voyage. The fever did not break. He was moved to a building beside a pool, then back to the palace, and by the end he recognized his officers but could no longer speak to them. Soldiers who suspected his death was being hidden insisted on filing past his bed, and he is said to have acknowledged each with his eyes.
A second tradition, preserved in the Alexander Romance and other later works, is more dramatic: Alexander cried out in pain after draining a great cup of wine, as if struck. That version feeds the oldest theory. Arrian, while making clear he did not believe it, set down the story that Antipater, the regent Alexander had left in Macedon and was about to replace, sent poison prepared by Aristotle; that Antipater’s son Cassander carried it to Babylon; and that his younger son Iollas, the royal cup-bearer, poured it. Some versions add Medius as an accomplice because he had arranged the party. The story suited the propaganda of Antipater’s enemies in the wars that followed, which is one reason historians are wary of it.
The explanations
Disease has been the favored answer. Babylon lay among canals and marshes, and malaria has long been suggested, although John Marr and Charles Calisher, writing in the CDC journal Emerging Infectious Diseases in 2003, argued that the sources describe a continuous fever rather than the cycling fevers of malaria. They proposed West Nile virus instead, pointing to a passage in Plutarch about a flock of ravens that behaved strangely and dropped dead at Alexander’s feet as he entered the city, behavior that resembles the bird die-offs that come before human outbreaks. A 1998 case discussion in the New England Journal of Medicine by David Oldach and colleagues at the University of Maryland favored typhoid fever, with a perforated bowel and the creeping paralysis that typhoid can occasionally cause. Others point to years of heavy drinking, pancreatitis, grief for his friend Hephaestion, who had died months earlier, or the wear of old wounds.
Toxicologists have looked at the poison claim on its merits. A 2014 review in Clinical Toxicology led by Leo Schep of New Zealand’s National Poisons Centre ruled out arsenic and strychnine as too fast and too violent for a twelve-day illness, and suggested that if Alexander was poisoned, the likeliest agent was white hellebore, Veratrum album, a plant the Greeks used as medicine. Its toxins can cause sudden stomach pain, nausea, a slowed heart and profound weakness, close to what the sources record.
The newest proposal came in 2018 from Katherine Hall, a lecturer at the University of Otago’s medical school in Dunedin. Writing in The Ancient History Bulletin, she argued for Guillain-Barré syndrome, a disorder in which the immune system attacks the nerves after an infection, often with Campylobacter bacteria. It can produce a paralysis that climbs from the legs while the mind stays clear, which matches a king who could not walk or speak but knew his men. Hall went further: shallow breathing under paralysis could have led doctors who relied on breath, not pulse, to pronounce him dead days too early. That would explain the ancient claim, often taken as a sign of divinity, that his body showed no decay for several days in the Babylonian summer.
Where it stands
No examination is possible. Ptolemy diverted Alexander’s funeral procession to Egypt, the body lay for centuries in a tomb at Alexandria visited by Roman emperors, and the site has since been lost. Every diagnosis rests on a handful of texts written long after the event, at least one of them shaped by propaganda. Poisoning cannot be excluded, but nothing points to it more strongly than to fever, and the cause of Alexander’s death remains unproven.