A Fateful Chill in the Forbidden City

In the winter of 1874, the Forbidden City stood shrouded in an uncommonly bitter cold. The northeast winds swept through the palace complexes with unusual intensity, carrying with them more than just the seasonal chill—they carried the seeds of a medical crisis that would soon grip the imperial household. Emperor Tongzhi, then just nineteen years of age, had always possessed a delicate constitution, but on this particular day, the harsh weather proved especially taxing on his system. As evening fell, the young ruler began experiencing alternating chills and fevers, prompting immediate concern among his attendants.

The court physicians were summoned without delay, with Li Deli, one of the most trusted medical officials, taking primary responsibility for the emperor’s care. His initial assessment seemed reassuringly straightforward—a severe cold that would likely resolve within a day or two with proper treatment. The physician attributed the illness to the extreme weather conditions and prescribed a warming herbal concoction intended to break the fever. This conventional approach to treating what appeared to be a common seasonal ailment followed established medical protocols of the Qing court, where external pathogens like wind and cold were routinely blamed for various maladies.

The Unfolding Medical Mystery

Despite Li Deli’s confident prognosis, the emperor’s condition failed to improve overnight. The persistence of symptoms soon attracted the attention of the two empress dowagers, Cixi and Ci’an, who personally visited the ailing monarch. Their concern reflected not only maternal affection but also political pragmatism—the health of the emperor directly impacted the stability of the Qing dynasty. Recognizing the inadequacy of the current accommodations, the dowagers ordered the emperor moved to the warmer Western Warmth Chamber of the Hall of Mental Cultivation, hoping that improved conditions might aid his recovery.

Three days passed with no improvement in the emperor’s condition. The initial diagnosis of a simple cold began to appear increasingly inadequate as new symptoms emerged: intense thirst, lower back pain, and urinary difficulties. Li Deli found himself grappling with a medical puzzle that defied conventional diagnosis. The physician’s growing unease stemmed from his awareness of the emperor’s private health issues—a subject too sensitive to discuss openly but potentially relevant to understanding the current illness.

The Emergence of Visible Symptoms

By the fourth day of illness, the clinical picture grew more complex with the addition of constipation and the appearance of purplish-red lesions on the emperor’s neck, shoulders, and back. Another court physician, Zhuang Shouhe, suggested these might indicate some form of eruptive disease, possibly measles. Li Deli cautiously agreed with this assessment, relieved to have identified what seemed to be a recognizable pattern.

Meanwhile, beyond the palace walls, rumors about the emperor’s condition began to circulate among government officials and the imperial clan. The unusual duration and severity of the illness raised concerns about its true nature. The two empress dowagers grew increasingly impatient with the physicians’ vague explanations and evasive responses during their daily briefings. The medical officials found themselves under intense pressure, their professional reputations and possibly their lives hanging in the balance.

The Diagnostic Turning Point

The critical breakthrough in diagnosis came not from medical texts but from palace gossip. Two eunuchs whispering in the corridors speculated that the emperor might have “seen happiness”—a euphemism for smallpox that reflected the traditional practice of referring to the disease auspiciously to avoid bad luck. Overhearing this conversation, the physicians experienced a moment of revelation. They immediately requested to re-examine the emperor, using the empress dowagers’ concerns about their proposed treatment as justification for this unusual request.

Upon closer examination, the truth became unmistakably clear. The lesions were indeed characteristic of smallpox, a disease that represented one of the most serious medical threats of the era. The diagnosis carried profound implications—smallpox had historically devastated populations worldwide, and even members of royalty were not immune to its deadly potential.

The Cultural Significance of Smallpox

In nineteenth-century China, smallpox occupied a unique place in both medical and cultural contexts. Referred to euphemistically as “seeing happiness” or “emerging blossoms,” the disease was understood as the manifestation of latent fetal toxins that everyone carried from birth. Surviving smallpox was believed to confer lifelong immunity, making the illness a sort of rite of passage—a dangerous but ultimately beneficial transformation.

This cultural framing explained why the physicians immediately offered congratulations to the emperor upon confirming their diagnosis. The ritualistic response reflected not medical callousness but rather a deeply ingrained cultural practice of transforming threatening situations into auspicious occasions through linguistic manipulation. The entire court would now need to participate in this fiction, treating the life-threatening illness as a celebratory event while simultaneously grappling with its grave medical reality.

Medical Management and Court Politics

The confirmed diagnosis of smallpox triggered a complex response that blended medical treatment with political maneuvering. The physicians prescribed cooling and moisturizing preparations to combat the internal heat that characterized the disease in Chinese medical theory. The emperor himself reported feeling as if his chest were burning, a symptom consistent with the high fevers typical of smallpox.

Meanwhile, Ronglu, the newly appointed head of the Imperial Household Department, found himself navigating treacherous political waters. The emperor’s illness threatened to destabilize the carefully maintained power balance between the conservative and reformist factions at court. As a key figure in the imperial administration, Ronglu had to manage both the medical crisis and its political ramifications while maintaining the appearance of calm control.

The Social Dimensions of Imperial Illness

The emperor’s illness reverberated far beyond the palace walls, affecting numerous aspects of Qing society. The imperial household implemented quarantine measures to prevent further spread of the disease, disrupting normal court functions and limiting access to the emperor. Officials throughout the bureaucracy adjusted their expectations and plans based on the uncertain prognosis, while the general population watched anxiously for news about their ruler’s condition.

Traditional smallpox treatments involved not only herbal medicine but also dietary restrictions, isolation practices, and ritual observances. The emperor would have been expected to follow a specific regimen aimed at drawing the toxins out of his system while supporting his vital energy. These practices reflected the holistic understanding of health in traditional Chinese medicine, which addressed physical, emotional, and spiritual dimensions of illness simultaneously.

The Historical Context of Smallpox in China

Smallpox had a long and devastating history in China, with records of epidemics dating back to the fourth century. The Qing dynasty itself had established precedents for managing imperial smallpox cases. The most notable previous instance involved the Shunzhi Emperor, who was widely believed to have died from the disease in 1661. That earlier tragedy had led to the ascension of the Kangxi Emperor, who had survived smallpox as a child and was therefore considered immune—a significant factor in his selection as successor.

This historical backdrop informed the contemporary response to Tongzhi’s illness. Court physicians would have consulted medical texts describing previous imperial cases, while officials would have studied historical precedents for managing succession crises. The political establishment understood that the emperor’s survival was uncertain and that contingency plans might need to be implemented.

Medical Understanding and Treatment Approaches

Nineteenth-century Chinese medicine approached smallpox through the framework of warm disease theory, which categorized infectious illnesses based on their seasonal patterns and symptomatic presentations. Physicians recognized the contagious nature of the disease and understood that some individuals possessed natural immunity. Treatment focused on managing symptoms, supporting the body’s natural healing processes, and guiding the proper eruption and resolution of the skin lesions.

The physicians faced the challenging task of balancing aggressive intervention against the need to support the emperor’s weakened constitution. Their use of cooling medications aimed to reduce the internal heat that threatened to consume the patient’s vital energy. At the same time, they had to ensure that the eruption process proceeded completely, as incomplete resolution was believed to leave toxins trapped within the body where they could cause future health problems.

The Psychological Dimensions of Royal Illness

The emperor’s illness placed enormous psychological pressure on all involved. For the young monarch himself, the physical suffering was compounded by anxiety about his survival and the stability of his reign. For the physicians, the stakes could not have been higher—failure to cure the emperor might result in severe punishment, while success would bring significant rewards. The empress dowagers faced the terrifying prospect of losing their son and the potential collapse of their political influence.

Court officials meanwhile navigated the delicate balance between showing appropriate concern and maintaining administrative functionality. The ritualized expressions of concern and the formalized medical reporting processes helped structure the response to the crisis, providing a framework for managing the uncertainty and fear that permeated the palace.

The Legacy of the Imperial Illness

The medical crisis of 1874 would have lasting implications for the Qing dynasty. The emperor’s survival remained uncertain for weeks, during which time the business of government continued under the guidance of the empress dowagers and senior officials. The episode highlighted the vulnerability of the imperial institution to health crises and underscored the importance of establishing clear succession mechanisms.

For Chinese medicine, cases such as this represented both challenges and opportunities. The treatment of high-profile patients allowed physicians to demonstrate their skills under extreme pressure, while the detailed record-keeping surrounding imperial illnesses provided valuable case studies for future generations of medical practitioners. The blending of medical, ritual, and political responses to serious illness reflected the holistic worldview that characterized traditional Chinese approaches to health and governance.

Modern Perspectives on Historical Diagnosis

Contemporary historians and medical researchers continue to debate the exact nature of the emperor’s illness. While the historical record clearly indicates a diagnosis of smallpox, some scholars have suggested alternative explanations based on the described symptoms and the emperor’s medical history. The documented presence of other health issues, possibly including sexually transmitted infections, may have complicated the clinical picture and affected his ability to fight off the infection.

The case illustrates the challenges of retrospective diagnosis, where modern medical knowledge must be carefully applied to historical descriptions that were shaped by different diagnostic frameworks and cultural understandings of disease. What remains clear is that the emperor faced a life-threatening illness that tested the limits of nineteenth-century medical knowledge and triggered complex political and social responses throughout the Qing empire.

Reflections on Medicine and Power

The medical crisis surrounding Emperor Tongzhi’s illness offers profound insights into the relationship between health and power in imperial China. The emperor’s body was not merely a biological entity but a political symbol, whose condition directly affected the stability of the state. The management of his illness involved not only medical considerations but also ritual performances, political calculations, and public communications designed to maintain confidence in the imperial institution.

This integration of medical and political responses reflects a worldview in which the health of the ruler was understood as interconnected with the wellbeing of the nation. The elaborate protocols governing the treatment of imperial illness served both practical and symbolic functions, addressing the biological reality of disease while simultaneously reinforcing the ideological foundations of imperial rule.

Enduring Historical Significance

The events of 1874 represent more than just a historical medical case study—they offer a window into the complex interplay of medicine, politics, and culture in late imperial China. The response to the emperor’s illness demonstrated the resilience of the Qing administrative system in managing crises, while also revealing the vulnerabilities of a political structure that depended heavily on the health and competence of a single individual.

The documented details of the case continue to inform our understanding of historical disease patterns, medical practices, and court life during the late Qing period. As historians piece together these events from palace records, official documents, and personal accounts, they contribute to a richer understanding of how premodern societies confronted health challenges that often blurred the boundaries between the biological, the political, and the spiritual.