The so-called Alexander Sarcophagus from Sidon (late 4th century BC), showing Alexander at the Battle of Issus — The 'Alexander Sarcophagus' from Sidon (late 4th century BC) — genuinely of Alexander's era, but a Sidonian king's tomb, not Alexander's.

The Death Mystery

Ten days of fever in Babylon, logged day by day in the Royal Journals — and 2,300 years of argument about what the fever was.

What the sources say

The fullest account is the Royal Journals (Ephemerides), quoted at length by Arrian (7.25–26) and Plutarch (Alex. 76–77). The sequence: Alexander feasted and drank with Medius of Larissa; that night he developed a fever; over the next ten days he bathed, sacrificed, gave orders, and grew steadily worse — able at first to talk and move, then speechless, then still. His soldiers filed past his bed. He died on Daisios 29/30 — conventionally 10/11 June 323 BC, aged thirty-two.

Plutarch and Arrian both record the poisoning rumors — that Antipater, fearing recall and execution, sent poison from Macedon, administered by his son Cassander as cupbearer, with Aristotle implicated in some versions — and both dismiss them. Arrian’s objection is practical: the Journals describe a days-long fever, and poison doesn’t work that way.

One detail the tradition preserves: Alexander’s body reportedly showed no decay for days in the Babylonian heat — taken as a sign of divinity then, and as a clue by modern diagnosticians now.

The modern theories

Malaria (Plasmodium falciparum). The long-standing favorite. Retief and Cilliers’ detailed review (2010, reaffirmed 2024) argues the Journals’ pattern — remittent fever over ~10 days, chills, decline — fits malignant tertian malaria, possibly aggravated by wounds, exhaustion, and heavy drinking. Babylon’s marshes were malarial country.

Typhoid fever. In 1998, University of Maryland physicians (Oldach et al., New England Journal of Medicine) argued for typhoid: the prolonged fever, the abdominal pain Alexander reportedly cried out with, the ~two-week course. The eminent Alexander historian Eugene Borza co-authored the paper — and publicly changed his mind from malaria.

West Nile encephalitis. A CDC analysis (Marr & Calisher, Emerging Infectious Diseases) proposed West Nile virus: endemic to the region, consistent with a two-week febrile illness with lethargy and coma. The hypothesis is medically serious and historically unprovable.

Guillain-Barré syndrome. In 2018, Dr. Katherine Hall proposed that an ascending paralysis (Guillain-Barré, triggered by a Campylobacter infection) explains the oddest details: Alexander’s progressive immobility with preserved awareness, and the body that didn’t decay — because, Hall argues, he may not have been dead when declared so. Ingenious, debated, unprovable.

Poison. The ancient rumor, revived periodically (strychnine, hellebore, arsenic via the Styx-water story). Modern toxicologists note the problems: most ancient poisons kill fast or don’t produce prolonged fever; a slow poison over ten days, dosed through court security, with no contemporary witness coming forward, strains belief. Most historians reject it; a minority keeps the door open.

Alcohol. The tradition stresses the drinking — the final party, the earlier killing of Cleitus, the famous drinking contests. Modern medicine: alcohol alone doesn’t produce this clinical course, though it could have weakened him for any of the infections above.

What we can actually say

Alexander died of a febrile illness lasting roughly ten days, in Babylon, in June 323 BC. That much the Journals establish — if the Journals are genuine, which is debated but widely accepted for this passage.
He was thirty-two, had accumulated serious wounds (the lung wound in India above all), drank heavily, and had spent years under extreme physical stress. Whatever the pathogen, the ground was prepared.
Everything else — malaria vs. typhoid vs. the rest — is retrospective diagnosis from a 2,300-year-old case report written by courtiers. Honest medicine says: suggestive, not conclusive.

Source notes

The Journals: Arrian 7.25–26; Plutarch, Alex. 76–77; the poisoning rumors at Arrian 7.27 and Plutarch, Alex. 77.
Retief & Cilliers, “The death of Alexander the Great,” Acta Theologica 26 (2010), reaffirmed 2024.
Oldach et al., “A Mysterious Death,” New England Journal of Medicine (1998).
Marr & Calisher, “Alexander the Great and West Nile virus encephalitis,” Emerging Infectious Diseases (CDC).
Hall, “Did Alexander the Great die from Guillain-Barré syndrome?” The Ancient History Bulletin (2018).

Limitations

Retrospective diagnosis cannot be confirmed; the Journals’ symptoms are reported at second or third hand.
The “body did not decay” detail may be legend, misobservation, or embalming practice — it cannot carry diagnostic weight alone.