An Unsettling Discovery in the Imperial Bath

In the autumn of 1874, during what appeared to be a routine bathing ritual in the Forbidden City, a personal attendant serving the Tongzhi Emperor made a startling discovery. As he assisted the young ruler with his bath, the servant noticed unusual rose-colored spots scattered across the emperor’s shoulders, back, and arms. These markings, neither raised nor itchy, formed various shapes—some circular, others resembling kidney beans—creating a pattern that seemed both delicate and alarming.

The attendant’s involuntary gasp caught the emperor’s attention. When questioned, the servant knew immediately that this was not something to conceal—indeed, impossible to hide from the sovereign himself. He fetched a mirror to show the emperor the mysterious markings, setting in motion a chain of events that would remain one of the most carefully guarded secrets of the Qing dynasty.

The Imperial Physician’s Dilemma

Summoned to examine the mysterious rash was Li Deli, one of the court’s most trusted physicians. After a thorough examination, the doctor found himself facing a medical and political predicament of unprecedented proportions. The symptoms presented a clinical picture that experienced physicians recognized immediately—a manifestation of secondary syphilis, known colloquially as “plum blossom” sores due to their distinctive appearance.

Li Deli prescribed a mild formulation of honeysuckle and other cooling herbs, presenting it as a simple remedy for minor skin irritation. Privately, however, he understood the gravity of the situation. The diagnosis, if confirmed, would represent not just a personal health crisis for the emperor but a potential dynastic catastrophe.

A Temporary Reprieve and False Hope

Within days, the emperor summoned Li Deli again, this time to the Hall of Mental Cultivation’s western chamber. The young monarch appeared relaxed, playing with his beloved Pekingese dogs, and reported that the treatment had been completely effective—the spots had vanished without a trace. The physician examined the emperor’s skin and indeed found it smooth and unmarked, prompting congratulations and reassurances that no further treatment was necessary.

The emperor, pleased with this outcome, rewarded Li Deli with gifts of fine silk and sable fur. Colleagues offered their congratulations, but behind the celebratory facade, Li Deli sought counsel from Zhang Benren, a renowned surgical specialist. Their whispered consultation confirmed Li Deli’s worst fears: the temporary disappearance of symptoms was characteristic of the disease’s progression, not its cure.

The Political Context: A Dynasty Under Pressure

This medical drama unfolded against a backdrop of significant political tension. The Qing government found itself embroiled in difficult negotiations with Japan regarding the Taiwan Expedition of 1874, which saw Japanese forces attacking aboriginal tribes in Taiwan. Japanese diplomat Ōkubo Toshimichi had delivered what amounted to an ultimatum, demanding a response within five days regarding compensation—initially framed as “military expenses” but later reframed as “compensation for victims.”

The timing could not have been more delicate. As the emperor’s physicians debated how to handle his medical condition, Prince Gong and other officials were engaged in high-stakes diplomacy that would ultimately result in China paying 500,000 taels of silver to Japan and acknowledging the justice of the Japanese expedition—a humiliating concession that reflected the weakening position of the Qing dynasty in international affairs.

Medical Ethics and Imperial Protocol

The diagnosis presented an extraordinary ethical challenge for the imperial physicians. In ordinary circumstances, doctors would be obligated to provide full disclosure to their patient and recommend appropriate treatment. However, when the patient was the Son of Heaven, different rules applied. The physicians found themselves caught between their professional duty and the overwhelming political implications of their diagnosis.

The medical team, including Li Deli and his superior Zhuang Shouhe, concluded that silence was their only viable option. They decided to “play ignorant”—to treat symptoms as they appeared without ever naming the disease explicitly. This approach reflected both the stigma associated with sexually transmitted infections and the particular vulnerability of the imperial institution to any suggestion of moral or physical corruption.

The Cultural Significance of Imperial Health

In traditional Chinese political philosophy, the emperor’s body served as a microcosm of the state itself. His physical well-being mirrored the health of the empire, while any illness or imperfection could be interpreted as reflecting broader dynastic weakness. This conceptual framework made the emperor’s medical condition a matter of state security rather than merely personal health.

The particular nature of the suspected illness carried additional cultural weight. Syphilis, often associated with moral failing and illicit sexual behavior, posed a direct challenge to the Confucian ideal of the ruler as a moral exemplar. For a dynasty already struggling to maintain its legitimacy in the face of internal rebellion and external pressure, such a diagnosis threatened to undermine the very foundation of imperial authority.

The Historical Context of Syphilis in China

Syphilis had been present in China since at least the early 16th century, when it likely arrived through maritime trade routes. By the 19th century, the disease was widespread throughout Chinese society, with well-established diagnostic categories and treatment protocols in traditional medicine. Medical texts described the condition’s progression through various stages, recognizing the characteristic rash that appears during secondary syphilis.

What made this case extraordinary was not the disease itself but the patient involved. The treatment protocols available—primarily involving mercury compounds in various preparations—were toxic and often caused significant side effects. Even with treatment, the disease could progress to its tertiary stage, causing neurological damage, gummatous lesions, and eventual death.

The Personal Tragedy of the Tongzhi Emperor

Behind the political implications lay a human story of a young man thrust into a position for which he was tragically unprepared. The Tongzhi Emperor had ascended to the throne as a child in 1861, following the death of his father, the Xianfeng Emperor. His reign was dominated by regents, particularly his mother, the Empress Dowager Cixi, who exercised real power behind the throne.

The emperor’s personal life reflected the tensions within the court. His marriage to Empress Xiaozheyi in 1872 had been a subject of political maneuvering, with different factions supporting different candidates. The young emperor’s suspected contraction of syphilis suggested extracurricular sexual activities that may have represented either rebellion against court control or simple youthful indiscretion with catastrophic consequences.

The Medical Response and Its Limitations

Faced with this impossible situation, the imperial physicians employed a strategy of minimal intervention. Rather than pursuing aggressive treatment with mercury—the standard approach for syphilis at the time—they opted for supportive care and symptom management. This approach reflected both practical considerations .

The physicians understood that even if the visible symptoms disappeared, the disease could remain dormant for years before reappearing in more severe form. They also recognized the risk of congenital transmission—that any children born to the emperor might inherit “fetal toxins,” as they termed congenital syphilis. This concern had direct implications for the succession and the future of the dynasty.

The Broader Implications for Qing Authority

The handling of the emperor’s illness reflected the growing fragility of Qing rule in the late 19th century. The decision to conceal rather than address the problem directly exemplified a pattern of avoiding difficult truths that characterized the dynasty’s response to multiple challenges during this period.

This incident occurred alongside other signs of dynastic decline, including military defeats, economic difficulties, and the growing influence of foreign powers in China. The inability to address the emperor’s health crisis honestly mirrored the court’s struggle to respond effectively to broader structural problems facing the empire.

Legacy and Historical Interpretation

The Tongzhi Emperor would die less than a year after this incident, in January 1875, at just 19 years of age. The official cause of death was given as smallpox, which was indeed circulating in Beijing at the time. However, the circumstances surrounding his death have fueled speculation among historians that syphilis may have been a contributing factor or even the primary cause.

The secrecy surrounding the emperor’s illness had profound consequences for the succession. With no heir produced—possibly due to the effects of his disease—power passed to his infant cousin, who became the Guangxu Emperor, with the Empress Dowager Cixi continuing as regent. This arrangement would extend her influence for decades to come, shaping the final years of the Qing dynasty.

Modern Perspectives on the Incident

Contemporary historians continue to debate the exact nature of the Tongzhi Emperor’s illness and its impact on Qing history. While some maintain that smallpox was indeed the cause of death, others point to circumstantial evidence suggesting advanced syphilis. What remains clear is that the handling of the medical crisis reflected broader patterns in late Qing governance.

The episode offers fascinating insights into the intersection of medicine, politics, and culture in imperial China. It illustrates how personal health matters could become affairs of state, and how medical decisions were often shaped by political considerations rather than purely clinical factors. The physicians’ dilemma—between professional ethics and political reality—remains a powerful example of the complex challenges faced by those serving absolute rulers.

Conclusion: A Dynasty’s Vulnerability Revealed

The discovery of those rose-colored spots on the emperor’s skin revealed more than just a personal health crisis—it exposed the vulnerabilities of an entire political system. The response to this medical mystery demonstrated how fear of scandal could override rational decision-making, how personal and political health became intertwined, and how difficult truths could be suppressed until they manifested in irreversible consequences.

This episode stands as a poignant metaphor for the Qing dynasty in its final decades: outwardly maintaining tradition and protocol while privately grappling with problems that threatened its very foundation. The physicians’ decision to “play ignorant” about the emperor’s condition mirrored the court’s broader approach to the challenges of modernization, foreign pressure, and internal decline—a strategy that ultimately proved inadequate to the task of preserving imperial power into the twentieth century.