Alexander's Last Days: Chronological Source Rearrangement (without the poison narrative and the romances)

[marcus]

Doctor Mario Bertolotti (La critica medica nella storia. Alessandro Magno, Torino, Fratelli Bocca editori, 1930, p. 356 s.) wrote: "Come potremo noi valutare, a distanza di secoli, le condizioni fisiologiche di quell'uomo in quell'istante [scil. Alexander before his last illness]? Supponiamo che un medico, fiduciario di una grande Società di previdenza sociale del nostro tempo, avesse dovuto proporre per un premio di assicurazione sulla vita il giovane Monarca, che da poco più di due anni aveva varcato la trentina: quale giudizio avrebbe egli potuto emettere? Sicuramente i dati anamnestici e l'etiologia non avrebbero concesso la possibilità di stabilire una valutazione molto favorevole, dacché il medico fiscale avrebbe dovuto registrare le malattie pregresse, gli accidenti traumatici ripetuti, ed i diuturni disagi della vita d'ogni giorno. Questo professionista del Novecento avrebbe quindi dovuto calcolare le invalidità temporanee pregresse e quelle permanenti consecutive alle molteplici ferite e i segni, forse ancora non completamente scomparsi, del paludismo e dell'ameba dissenterica. Tirate le somme, era fatalmente riconoscibile la precarietà di vita del grande conquistatore: pochi giorni contati rimanevano, prima che le parche ne tagliassero il filo."

If it helps, I've just put this through the translation thingy in Microsoft Word (as I don't read Italian very well), and for reference:
"How can we evaluate, centuries later, the physiological condition of that man at that instant [scil. Alexander before his last illness]? Suppose that a doctor, trustee of a great social security society of our time, had to propose for a life insurance premium the young monarch, who had been in his thirties a little more than two years before: what judgment could he have made? Certainly, the anamnestic data and the etiology would not have allowed the possibility of establishing a very favorable evaluation, since the fiscal physician would have had to record the previous illnesses, the repeated traumatic accidents, and the daily discomforts of everyday life. This twentieth-century professional would therefore have had to calculate the previous temporary disabilities and the permanent ones following the multiple wounds and the signs, perhaps not yet completely disappeared, of paludism and dysenteric amoeba. Summing up, the precariousness of the great conqueror's life was fatally recognisable: a few days remained before the fates cut the thread."

[Alexias]

I think we can all agree that Alexander pushed himself physically very hard. To quote Ryan Reynolds, at 19 you're made of rubber and magic. But at 30 you are not, some of that elastic is wearing thin, particularly if you have repeatedly been pushing your endurance, as well as coping with constant pressures of responsibility, decision-making and strain, and drinking heavily into the bargain. Alexander almost certainly would have burnt himself out before he reached middle-age unless he eased up. You can't but help thinking of modern rock stars who have lived hard and died young.

Many historians cite exhaustion, grief over Hephaestion's death, and the cumulative effects of his wounds as the reasons why Alexander, even at a comparatively young age, could not throw off the effects of his final illness. (Sorry, don't have any books here to quote from.)

It is very likely that Alexander had scar tissue on his lungs from the Mallian arrow wound. Air and blood were said to have escaped from the wound when the removed the arrow. It is also possible that he may have had scarring on his lungs from his illness in Tarsus, another fever that wouldn't break, if it was pneumonia. This illness though may have been malaria, as might his final illness. This doesn't preclude a complication of pneumonia though.

Yet we cannot definitively prove any of this, any more than we can prove the poisoning theory. All we can do is make educated and probable guesses based on the available evidence. And, after nearly two and a half thousand years, we are lucky to have as much evidence as we do have.

[hiphys]

Thank you, Marcus, good job! And many thanks also to Alexias for summing up so well the entire argument!

[AdamKvanta]

... del paludismo e dell'ameba dissenterica.

So Bertolotti said he died from malaria and amoebic dysentery (amoebiasis). But I see no arguments why. Just like for pneumonia, the malaria (P. vivax) fatality rate for healthy young men is extremely low and this is true also for amoebiasis. Previous physical injuries from which Alexander fully recovered didn't make him more susceptible to these diseases. Nor his binge drinking.

I already cited sources for malaria.

Amoebiasis usually comes from unsanitized water or food. Alexander drank wine all the time so the alcohol in the wine would have neutralized any infected meal or drink. Of course, we have no report that other people had dysenteries at that time, so it's unlikely anyway.
Wikipedia says it is rare to have any symptoms at all: "Most infected people, about 90%, are asymptomatic". - https://en.wikipedia.org/wiki/Amoebiasis
And again, healthy young men are not at risk:

Amoebic infections tend to be most severe in the following populations:

• Pregnant women

• Postpartum women

• Neonates

• Malnourished individuals

• Individuals who are on corticosteroids

• Individuals with malignancies

https://www.ncbi.nlm.nih.gov/books/NBK519535/

Just because some diseases have similar symptoms as Alexander's doesn't mean that these diseases are the probable cause of Alexander's illness. And I'm looking for the most probable cause.

[AdamKvanta]

I think we can all agree that Alexander pushed himself physically very hard. To quote Ryan Reynolds, at 19 you're made of rubber and magic. But at 30 you are not, some of that elastic is wearing thin, particularly if you have repeatedly been pushing your endurance, as well as coping with constant pressures of responsibility, decision-making and strain, and drinking heavily into the bargain. Alexander almost certainly would have burnt himself out before he reached middle-age unless he eased up. You can't but help thinking of modern rock stars who have lived hard and died young.

Many historians cite exhaustion, grief over Hephaestion's death, and the cumulative effects of his wounds as the reasons why Alexander, even at a comparatively young age, could not throw off the effects of his final illness. (Sorry, don't have any books here to quote from.)

It is very likely that Alexander had scar tissue on his lungs from the Mallian arrow wound. Air and blood were said to have escaped from the wound when the removed the arrow. It is also possible that he may have had scarring on his lungs from his illness in Tarsus, another fever that wouldn't break, if it was pneumonia. This illness though may have been malaria, as might his final illness. This doesn't preclude a complication of pneumonia though.

Yet we cannot definitively prove any of this, any more than we can prove the poisoning theory. All we can do is make educated and probable guesses based on the available evidence. And, after nearly two and a half thousand years, we are lucky to have as much evidence as we do have.

I agree Alexander pushed himself physically very hard sometimes but not all the time. He had time to recover and it seems he recovered from all his injuries because he was able to cross the Gedrosian desert. He wasn't physically pushing very hard at Babylon and I don't see why he would be exhausted or burnt out at that time. And also he wasn't grieving anymore in Babylon.

Yes, he was sometimes binge drinking. Just like college students do. They are not dying from pneumonia though. Binge drinking doesn't equal chronic alcoholism with long-term adverse health effects. I think he would need to drink daily for at least 20 years to see any adverse effects of alcoholism. At 32 and with occasional binge drinking, Alexander was not a typical immunosuppressed chronic alcoholic.

I agree that Alexander had scar tissue on his lungs from the Mallian arrow wound. Any pneumothorax would leave a scar. But a small scar (from the tip of the arrow) is not a problem:

Small areas of lung scarring typically aren’t serious.
https://www.healthline.com/health/lung- ... ng-serious

And I already cited that pneumothorax usually doesn't have any long-term adverse effects.

I agree that if Alexander had extensive scarring it would be a potential problem. But not two years later but probably that very day or week of injury. Or during the crossing of the desert. So he probably didn't have extensive scarring.

And finally, did Alexander have pneumonia at Tarsus? I don't think so. According to Arrian, Alexander had convulsions and pneumonia doesn't cause convulsions. According to Curtius, it was an obscure illness and there is no report that anybody else was affected, only Alexander. But there was a report that Darius tried to poison him. And this is what I think happened. He was poisoned but not by Philip the Acarnanian. He was probably poisoned by Parmenion. I'd rather make a new thread about this.

[hiphys]

On the subject of Alexander's Mallian arrow wound Curtius wrote (9, 5, 23): "They stripped him naked and observed that the arrow was barbed and could only be removed without serious damage to Alexander if the wound were surgically enlarged. (24) They feared, however, that the operation would be impeded by profuse bleeding, since the arrow buried in his flesh was huge and apparently penetrated his vital organs. (25) Critobulus was a doctor possessed of extraordinary skill, but in such a critical situation he was terrified, fearing to undertake the operation in casean unsuccessful outcome resulted in serious repercussions for himself. (26)...[Alexander] said to the doctor: 'Why are you waiting? What is the moment you are waiting for? If I have to die, why do you not at least free me from this agony as soon as possible? Or are you afraid of being held responsible for my having received an incurable wound? (27) Eventually his fear passing or else hidden, Critobulus started urging Alexander to let himself be held down until he extracted the arrow-head, since even a slight movement of the body would have grave consequences. (28) The king declared that he had no need of people to hold him and, following instructions, he submitted his body to the knife without flinching. So THE WOUND WAS ENLARGED and the barbed head extracted. A stream of blood now began to gush forth." Therefore even if the arrow wound was at first small it was later enlarged surgically, becoming a second and more dangerous wound. And Alexander bore it life-long.

[AdamKvanta]

Therefore even if the arrow wound was at first small it was later enlarged surgically, becoming a second and more dangerous wound. And Alexander bore it life-long.

But we don't know whether his lungs were cut again. They certainly needed to cut the flesh from the barbed arrowhead. However, the barbs are at the bottom of the head but I presume that it was only the top of the head that penetrated the lungs. That would mean only his flesh wound was enlarged but not his lung wound. And only the lung wound is relevant to pneumonia. So again, we don't have proof that his lungs were cut again and that his lungs were extensively scarred.