A Throne in Peril: The Emperor’s Mysterious Illness

In the winter of 1874, the Forbidden City was shrouded in anxiety. The young Tongzhi Emperor, only in his late teens, lay gravely ill within the palace walls. Court physicians struggled to diagnose and treat his condition, which appeared to be a severe case of smallpox—a disease that had haunted Chinese emperors for centuries. The imperial physicians, led by Li Deli, faced an impossible situation: how to treat an emperor whose recovery was crucial for political stability, yet whose symptoms suggested a deeper, more troubling prognosis.

The medical team understood the symbolic weight of their treatments. When discussions turned to using ginseng—the “king of medicines” believed to prolong life—the physicians hesitated. Such a powerful treatment would signal desperation, potentially causing panic among officials and the public. Even the two empress dowagers agreed that using ginseng would create “too great a disturbance,” preferring more cautious approaches. This hesitation revealed the complex interplay between medicine and politics in imperial China, where a ruler’s health was never merely a private matter.

The Political Calculations Behind the Sickbed

As the emperor’s condition worsened, political maneuvering intensified behind palace walls. Prince Dun, a senior member of the imperial clan, approached Prince Gong with the delicate suggestion that they should consider designating an heir—a move that acknowledged the emperor might not recover. This was no simple matter of succession; it represented a potential seismic shift in Qing dynasty politics.

The selection of an heir involved complex genealogical calculations. The only suitable candidates were two infants from the Pu generation of the Xuanzong line. The preferred choice was Pu Kan, just eight months old, son of Zai Zhi. But Zai Zhi himself was not a direct descendant of Emperor Xuanzong—he had been adopted into the imperial line from the house of Prince Cheng, a grandson of Emperor Qianlong. This raised the specter of the throne passing to a collateral branch of the family, potentially disrupting the direct imperial lineage.

Prince Gong recognized the dangers. He remembered the Ming dynasty precedent when the Jiajing Emperor, originally a provincial prince, had ascended the throne and subsequently demoted his predecessor’s status. A similar scenario could unfold if a descendant of Prince Cheng took the throne, potentially marginalizing the descendants of Emperor Renzong. The empress dowagers and other imperial relatives would certainly oppose such an outcome. Prince Gong advised caution, suggesting they first sound out the empress dowagers’ opinions before proceeding further.

The Medical Crisis Deepens

The emperor’s physicians found themselves in an increasingly impossible position. Li Deli privately admitted he had lost confidence in treating the emperor’s condition, while another physician, Han Jutong, could only repeat that the smallpox toxins had penetrated deeply into the emperor’s system and would be difficult to eliminate. Neither dared speak the full truth about the emperor’s condition.

Medical terminology of the time described the emperor’s state in alarming terms. According to traditional Chinese medical principles, the “five favorable signs” were absent while the “seven adverse signs” were all present—a grave prognosis. The physicians faced a therapeutic dilemma: using strong tonifying treatments risked causing excessive yang energy, while cooling treatments might further damage the emperor’s already weakened qi. The real nature of the illness remained unspoken, though rumors circulated that the emperor’s mind was already wandering, approaching his final hours.

Contradictory reports emerged from the palace. While physicians privately expressed pessimism, eunuchs close to the emperor reported improvements, claiming his spirits were good and he even sat up to tell jokes. These conflicting accounts created an atmosphere of suspicion and uncertainty throughout the imperial court.

The Political Theater of Imperial Illness

Recognizing the growing unease, Prince Gong petitioned the empress dowagers to allow senior officials—including members of the Grand Council, imperial relatives, and respected scholars—regular access to see the emperor. This, he argued, would calm rumors and stabilize political nerves. The empress dowagers agreed in principle, though Empress Dowager Cixi insisted on waiting for a day when the emperor appeared particularly well before implementing the plan.

The carefully staged viewing eventually took place. Officials were admitted to the eastern warming chamber of the Hall of Mental Cultivation, where they found the emperor propped up against a eunuch. He appeared reasonably alert, though his voice was hoarse. The visible signs of smallpox—scabs only half shed—confirmed the seriousness of his condition. The emperor’s questions about the date and his concern about affairs in the twelfth month revealed his awareness of his responsibilities, even as his physical condition deteriorated.

This performance of imperial normalcy could not conceal the underlying crisis. When the emperor confessed he felt hot and thirsty and couldn’t calm himself, he revealed the physical discomfort that belied the official narrative of improvement.

The Search for Alternative Treatments

As confidence in the court physicians waned, officials began suggesting alternative treatments. Weng Tonghe, dissatisfied with Li Deli’s approach, finally voiced what many had been thinking: after a month of illness, the emperor’s condition had progressed beyond the initial phase and required a different kind of specialist.

The conversation turned to an eighty-nine-year-old physician named Qi Zhong, renowned for treating external conditions. Rong Lu, a senior official, recommended summoning this elderly doctor, noting his vast experience might offer solutions that had eluded the court physicians. The empress dowagers agreed, and Qi Zhong was brought to the palace—a significant departure from standard practice that indicated the desperation of the situation.

The arrival of the elderly physician, supported by two palace attendants as he made his way to the emperor’s bedside, represented both hope and acknowledgment that conventional treatments had failed. His examination lasted nearly half an hour, after which he was summoned to report directly to the empress dowagers in the western warming chamber. Qi Zhong identified the core issue: the severe ulceration around the emperor’s waist, a symptom that pointed to complications beyond simple smallpox.

The Cultural Context of Imperial Illness

The emperor’s illness must be understood within its broader cultural and medical context. In nineteenth-century China, the emperor’s body was more than a physical entity—it represented the health of the state itself. The concept of “tianxia” positioned the emperor as the crucial link between heaven and earth, whose personal well-being directly affected cosmic harmony.

Smallpox had particular significance in Chinese imperial history. Several Qing emperors had contracted the disease, with varying outcomes. The Kangxi Emperor had survived smallpox as a child, which actually strengthened his claim to the throne since survivors were considered to have heaven’s protection. For Tongzhi, however, the disease arrived at a vulnerable political moment, compounding existing tensions within the imperial court.

Traditional Chinese medicine approached such illnesses through complex diagnostic frameworks that considered balance between yin and yang, the flow of qi, and the interaction of the five phases. Treatments were not merely physical but sought to restore harmony between the body and the cosmos. The physicians’ dilemma—whether to use strong tonics or cooling treatments—reflected deeper philosophical questions about how to restore balance to a system in extreme distress.

The Social Dimensions of the Crisis

Beyond the palace walls, the emperor’s illness reverberated through Qing society. Although ordinary subjects would learn details only gradually, the sense of imperial vulnerability affected the political atmosphere. The Qing dynasty had already faced massive challenges through the Opium Wars and Taiping Rebellion; a succession crisis threatened further instability.

Within the bureaucracy, officials positioned themselves for various outcomes. Factions aligned with different potential successors began subtle maneuvering, while those loyal to the current emperor hoped for his recovery. The uncertainty affected governance, as major decisions were postponed pending resolution of the health crisis.

The imperial household itself was divided. Empress Dowager Cixi and Empress Dowager Ci’an had different perspectives on the crisis, reflecting their distinct positions and influences. The young empress, Tongzhi’s wife, found herself in an increasingly precarious position as her husband’s health declined, with her future status dependent on the outcome of his illness and any succession decisions.

The Legacy of the 1874 Crisis

The medical and political crisis of 1874 had profound consequences for the Qing dynasty. The emperor did not recover, dying in January 1875 without a designated heir. The succession question was resolved by placing Cixi’s nephew on the throne as the Guangxu Emperor, a decision that consolidated her power but created new tensions within the imperial family.

The episode revealed the limitations of imperial medicine when confronted with serious illness. Despite the sophisticated theoretical framework of traditional Chinese medicine, the court physicians could not save their patient. This failure contributed to growing skepticism about traditional approaches and eventually paved the way for greater acceptance of Western medicine in China.

Politically, the crisis demonstrated the vulnerability of the imperial system when the ruler was incapacitated. The elaborate mechanisms for handling succession proved inadequate when confronted with an unexpected early death without a clear heir. The resolution—effectively a political compromise that bypassed strict genealogical principles—set a precedent that would influence later succession questions.

The events of 1874 also highlighted the continuing power of the empress dowagers, particularly Cixi, who would dominate Chinese politics for another three decades. Her handling of the medical and succession crises demonstrated her political skill but also revealed the system’s dependence on individual leadership rather than institutional structures.

Modern Relevance and Historical Reflection

The crisis of 1874 offers enduring lessons about the intersection of medicine, politics, and leadership. The tension between public confidence and private reality, the challenge of making decisions under uncertainty, and the difficulty of balancing expert advice with political considerations remain relevant to modern governance.

The episode also illustrates how medical crises can accelerate political change. The Tongzhi Emperor’s illness and death disrupted the expected course of succession, contributing to the power dynamics that would ultimately influence China’s response to twentieth-century challenges.

Historians continue to debate the exact nature of the emperor’s illness, with some suggesting complications beyond smallpox may have been involved. What remains clear is that the medical crisis became a political crisis, demonstrating how the personal health of a leader can shape national destiny.

The story of the ailing emperor, his physicians, and the courtiers maneuvering around his sickbed reminds us that history often turns on such intimate human dramas. Behind the grand narratives of empires and dynasties lie individual stories of suffering, hope, and the relentless pursuit of power—themes as relevant today as in the winter of 1874.