Response to letter to the Editor regarding “A note on Conium maculatum L., the plant that defeated Alexander the Great” in Clinical Toxicology 2014: (doi: 10.3109/15563650.2013.870341)

To the Editor:

We thank Wiart for his interest in our paper in which we put forward our hypothesis for the cause of Alexander the Great's death.¹ Wiart challenges our conclusion, “If Alexander the Great was poisoned, Veratrum album offers a more plausible cause than arsenic, strychnine, and other botanical poisons”. In our manuscript we investigated the toxicological properties of a number of botanical poisons known to the ancients and concluded that, based on one account of his death, poisoning by V. album offers the most plausible explanation.

Wiart suggests that Conium maculatum is a better match for Alexander's final illness. Typically, as we described in our paper, C. maculatum, produces features rapidly. It is unlikely that poison hemlock would cause a prolonged illness leading to death 11 to 12 days post-ingestion. C. maculatum can cause death within hours in severe poisoning,² with rapid loss of consciousness and respiratory arrest,^2,3 sometimes after an initial stimulatory phase.³ Veratrum, on the other hand, has been shown to cause an illness extending up to 15 days post-exposure.⁴ While Alexander was described as weak throughout his final illness, he remained conscious until just before death. Veratrum poisoning causes hypotension and bradycardia which leaves the victim weak and immobile yet fully conscious. We believe the symptoms of Veratrum poisoning closely match Alexander's illness based on the account described in the Alexander Romance, while C. maculatum does not.

Wiart comments on Androcydes’ advice to Alexander and suggests that Alexander was advised to drink wine as an antidote to C. maculatum. We do not believe that this interpretation is correct. What Alexander's physician essentially said, using a parallel with deadly hemlock, was “Ease up on the drink, its poisonous”. Advice that is as pertinent today as it was in Alexander's time!

Wiart also suggested that V. album could not have been the cause of Alexander's death as it does not grow near the Euphrates River. V. album is, as described in our paper, found across alpine regions of Europe and Western Asia and its emetic properties were well recognized and exploited by the ancient Greeks. Even if this plant was not distributed around the Euphrates or Babylon in Alexander’s time it cannot be discounted as a possible cause of his death as it could easily have been kept as a fermented liquid or powder. As it was regarded as a medicinal product,⁵ the military doctors of the day would most likely have stocks of powder or liquid to treat soldiers. It would not be difficult for those implicated in the poison plot, particularly his cup bearer Iollas, to obtain these formulations of V. album in order to spike Alexander's wine. They would not need to rely on local flora.

The cause of Alexander's death will always remain a mystery. However, based on the account described in the Alexander Romance, we believe V. album still offers the most plausible explanation.

Declaration of interest

The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.