The first personality was that of a miracle worker who beamed himself and his entourage of monks across the Ganges River (D II, 89), who had a divine vision of the settlement of gods on earth (D II, 87), who could live until the end of the world on condition that someone invite him to do so (D II, 103), who determined the time of his own death (D II, 105), and whose death was glorified by the shower of heavenly flowers and sandal powder and divine music (D II, 138). 

The other personality was that of an aged being who was failing in health (D II, 120), who almost lost his life because of a severe pain during his last retreat at Vesali (D II, 100), and who was forced to come to terms with his unexpected illness and death after consuming a special cuisine offered by his generous host. 

These two personalities take turns emerging in different parts of the narrative. Moreover, there also appear to be two explanations of the Buddha's cause of death: One is that the Buddha died because his attendant, Ananda, failed to invite him to live on to the age of the world or even longer (D II, 117). The other is that he died by a sudden illness which began after he ate what is known as "Sukaramaddava" (D II, 127-157). 

The former story was probably a legend, or the result of a political struggle within the Buddhist community during a stage of transition, whereas the latter sounds more realistic and accurate in describing a real life situation that happened in the Buddha's last days.

A number of studies have focused on the nature of the special cuisine that the Buddha ate during his last meal as being the agent of his death. However, there is also another approach based on the description of the symptoms and signs given in the sutta, which modern medical knowledge can shed light on. 

The sutta itself provides details concerning the signs and symptoms of his illness in addition to some reliable information about his circumstances over the previous four months, and these details are also medically significant.

The sutta begins with King Ajatasattus' plot to conquer a rival state, Vajji. The Buddha had journeyed to Vajji to enter his last rainy-season retreat. It was during this retreat that he fell ill. The symptoms of the illness were sudden, severe pain. 

However, the sutta provides no description of the location and character of his pain. It mentions his illness briefly, and says that the pain was intense, and almost killed him.

A description of the miracle of the unseasonal blooming of leaves and flowers on the sala trees, when the Buddha was laid down between them, indicates the time frame given in the sutta. 

While eating, he felt there was something wrong with the food and he suggested his host have the food buried. Soon afterward, he suffered severe stomach pain and passed blood from his rectum. 

We can reasonably assume that the illness started while he was having his meal, making him think there was something wrong with the unfamiliar delicacy. Out of his compassion for others, he had it buried. 

Was food poisoning the cause of the illness? It seems unlikely. The symptoms described do not indicate food poisoning, which can be very acute, but would hardly cause diarrhoea with blood. Usually, food poisoning caused by bacteria does not manifest itself immediately, but takes an incubation period of two to 12 hours to manifest itself, normally with acute diarrhoea and vomiting, but not the passage of blood. 

Another possibility is chemical poisoning, which also has an immediate effect, but it is unusual for chemical poisoning to cause severe intestinal bleeding. Food poisoning with immediate intestinal bleeding could only have been caused by corrosive chemicals such as strong acids, which can easily lead to immediate illness. But corrosive chemicals should have caused bleeding in the upper intestinal tract, leading to vomiting blood. None of these severe signs are mentioned in the text.

Peptic ulcer diseases can be excluded from the list of possible illnesses as well. In spite of the fact that their onset is immediate, they are seldom accompanied by bloody stool. A gastric ulcer with intestinal bleeding produces black stool when the ulcer penetrates a blood vessel. An ulcer higher up in the digestive tract would be more likely to manifest itself as bloody vomiting, not a passage of blood through the rectum.

Other evidence against this possibility is that a patient with a large gastric ulcer usually does not have an appetite. By accepting the invitation for lunch with the host, we can assume that the Buddha felt as healthy as any man in his early 80s would feel. Given his age we cannot rule out that the Buddha did not have a chronic disease, such as cancer or tuberculosis or a tropical infection such as dysentery or typhoid, which could have been quite common in the Buddha's time. 

These diseases could produce bleeding of the lower intestine, depending on their location. They also agree with the history of his earlier illness during the retreat. But they can be ruled out, since they are usually accompanied by other symptoms, such as lethargy, loss of appetite, weight loss, growth or mass in the abdomen. None of these symptoms were mentioned in the sutta.

The mesentery is a part of the intestinal wall that binds the whole intestinal tract to the abdominal cavity. An infarction of the vessels of the mesentery normally causes the death of the tissue in a large section of the intestinal tract, which results in a laceration of the intestinal wall. 

This normally produces severe pain in the abdomen and the passage of blood. The patient usually dies of acute blood loss. This condition matches the information given in the sutta. It is also confirmed later when the Buddha asked Ananda to fetch some water for him to drink, indicating intense thirst. 

As the story goes, Ananda refused, as he saw no source for clean water. He argued with the Buddha that the nearby stream had been muddied by a large caravan of carts. But the Buddha insisted he fetch water anyway. 

A question arises at this point: Why did the Buddha not go to the water himself, instead of pressing his unwilling attendant to do so? The answer is simple. The Buddha was suffering from shock caused by severe blood loss. He could no longer walk, and from then to his death bed he was most likely carried on a stretcher. 

If this was indeed the situation, the sutta remains silent about the Buddha's travelling to his deathbed, possibly because the author felt that it would be an embarrassment for the Buddha. Geographically, we know that the distance between the place believed to be the house of Cunda and the place where the Buddha died was about 15 to 20 kilometres. It is not possible for a patient with such a grave illness to walk such a distance. 

More likely, what happened was that the Buddha was carried on a stretcher by a group of monks to Kusinara (Kushinagara). 

It remains a point of debate whether the Buddha really determined to pass away at this city, presumably not much larger than a town. From the direction of the Buddha's journey, given in the sutta, he was moving north from Rajagaha. It is possible that he did not intend to die there, but in the town where he was born, which would have taken a period of three months to reach.

From the sutta, it is clear that the Buddha was not anticipating his sudden illness, or else he would not have accepted the invitation of his host. Kusinara was probably the nearest town where he could find a doctor to take care of him. It is not difficult to see a group of monks hurriedly carrying the Buddha on a stretcher to the nearest town to save his life.

Normally, the pain is triggered by a large meal, which requires a higher flow of blood to the digestive tract. As the obstruction persists, the bowel is deprived of its blood supply, which subsequently leads to an infarction, or gangrene, of a section of the intestinal tract. This in turn results in a laceration of the intestinal wall, profuse bleeding into the intestinal tract, and then bloody diarrhoea.

With the progress of the illness, some of the mucosal lining of his intestine sloughed off, and this site became the origin of the bleeding. Arteriosclerosis, the hardening of the vessel wall caused by ageing, was the cause of the arterial occlusion, a small blockage that did not result in bloody diarrhoea, but is a symptom, also known to us as abdominal angina.

He had his second attack while he was eating the Sukaramaddava. The pain was probably not intense in the beginning, but made him feel that there was something wrong. Suspicious about the nature of the food, he asked his host to have it all buried, so that others might not suffer from it.

Soon, the Buddha realised that the illness was serious, with the passage of blood and more severe pain in his abdomen. Due to the loss of blood, he went into shock. The degree of dehydration was so severe that he could not maintain himself any longer and he had to take shelter at a tree along the way. 

Feeling very thirsty and exhausted, he got Ananda to collect water for him to drink, even though he knew that the water was muddied. It was there that he collapsed until his entourage carried him to the nearest town, Kusinara, where there would have been a chance of finding a doctor or lodging for him to recover in. 

It was probably true that the Buddha got better after drinking to replace his fluid loss, and resting on the stretcher. The experience with the symptoms told him that his sudden illness was the second attack of an existing disease. He told Ananda that the meal was not the cause of his illness, and that Cunda was not to blame.

A patient with shock, dehydration and profuse blood loss usually feels very cold. This was the reason why he told his attendant to prepare a bed using four sheets of ifsanghati nf. According to Buddhist monastic discipline, a ifsanghati nfis a cloak, or extra piece of robe, very large, the size of a bed sheet, which the Budd ha allowed monks and nuns to wear in winter.

This information reflects how cold the Buddha felt because of his loss of blood. Clinically, it is not possible for a patient who is in a state of shock with severe abdominal pain, most likely peritonitis, pale and shivering, to be ambulatory. 

The Buddha was most likely put into a lodging, where he was nursed and warmed, located in the city of Kusinara. This view is also confirmed with the description of Ananda who, weeping, swoons and holds onto the door of his lodge after learning that the Buddha was about to pass away.

Normally, a patient with mesenteric infarction could live 10 to 20 hours. From the sutta we learn that the Buddha died about 15 to 18 hours after the attack. During that time, his attendants would have tried their best to comfort him, for example, by warming the room where he was resting, or by dripping some water into his mouth to quench his lingering thirst, or by giving him some herbal drinks. But it would be highly unlikely that a shivering patient would need someone to fan him as is described in the sutta.