A physician's view of: What caused the Lord Buddha's Death
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.
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.
In another mural painting at Wat Ratchasittharam, the Lord Buddha is approaching death, but he still takes time to answer questions put forth by the ascetic Subhadda, his last convert who, after being admitted to the Buddhist Order, became an arahant (enlightened monk).
What we know
In the Mahaparinibbana Sutta, we are told that the Buddha became ill suddenly after he ate a special delicacy, Sukaramaddava, literally translated as "soft pork", which had been prepared by his generous host, Cunda Kammaraputta.
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 Buddha did not accept the invitation right away.
When the sutta was composed, its author was under the impression that the Buddha died, not because of the food he ate, but because he already had an underlying illness that was serious and acute-and had the same symptoms of the disease that finally killed him.
Theravada Buddhist tradition has adhered to the assumption that the historical Buddha passed away during the night of the full moon in the lunar month of Visakha (which falls sometime in May to June).
But the timing contradicts information given in the sutta, which states clearly that the Buddha died soon after the rainy-season retreat, most likely during the autumn or mid-winter, that is, November to January.
But from the descriptions given, the onset of the illness was quick.
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.
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.
A gastric ulcer with intestinal bleeding produces black stool when the ulcer penetrates a blood vessel.
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.
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.
A large haemorrhoid can cause severe rectal bleeding, but it is unlikely that a haemorrhoid could cause severe abdominal pain unless it is strangulated. But then it would have greatly disturbed the walking of the Buddha to the house of his host, and rarely is haemorrhoid bleeding triggered by a meal.
A disease that matches the described symptoms-accompanied by acute abdominal pain and the passage of blood, commonly found among elderly people, and triggered by a meal-is mesenteric infarction, caused by an obstruction of the blood vessels of the mesentery.
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.
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.
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.
Before passing away, the Buddha told Ananda that Cunda was not to be blamed and that his death was not caused by eating Sukaramaddava. The statement is significant. The meal was not the direct cause of his death.
Progression of the disease
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.
The disease gets worse as the liquid and content of the intestine oozes out into the peritoneal cavity, causing peritonitis or inflammation of the abdominal walls. This is already a lethal condition for the patient, who often dies due to the loss of blood and other fluid.
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.
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.
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.
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.
Most of his last words could have been true, and they were memorised by generations of monks until they were transcribed.
The hypothesis outlined above explains several scenes in the narrative of the sutta, namely, the pressuring of Ananda to fetch water, the Buddha's request for a fourfold cloak for his bed, the ordering of the meal to be buried, and so on.
It also reveals another possibility of the actual means of transportation of the Buddha to Kusinara and the site of his death bed. Sukaramaddava, whatever its nature, was unlikely to have been the direct cause of his illness.
Rather, it was the size of the meal, relatively too large for his already troubled digestive tract, that triggered the second attack of mesenteric infarction that brought an end to his life./.