The Best Doctor Is Also a Historian
The Rootcutter's inaugural essay series aims at exploring connections between ancient and modern medicines—and not only the connections we make, but also why we make those connections and what impact they have on how we think about and conduct modern medical practices, both as healthcare experts and as service users. This series has been generously funded by the Society for Classical Studies Ancient Worlds, Modern Communities grant.
Image: Detail from Descent from the Cross, Rogier van der Weyden, c. 1435.
Public Domain (Wikipedia Commons).
by Jessica Wright
July 26, 2022
A 19th-century German literary scholar introduces a medical interpretation of the ancient Greek theatre term "catharsis" that shapes future approaches to mental disorder. Wright examines this history of this term and shows how literary and psychotherapeutic theories continue to influence one another.
Dr Jessica Wright is a historian and essayist. Recent work includes "On What Is in Our Power" (Michigan Quarterly Review) and "On Sponges" (Foglifter Journal). Her first book, The Care of the Brain in Early Christianity, is forthcoming from UC Press (2022).
Below the surface of modern medicine, there is a network of ancient ideas—some dead roots that mat the soil, others that cling tenaciously to life, still sprouting new shoots.
Take the word catharsis.
Most of the time, when we think about catharsis, we imagine ourselves at the movies—crying, perhaps, as the credits roll, or possibly angry at a villain who conveniently deserves no sympathy. Have a good cry, we tell ourselves. Let it all out.
Aristotle's Poetics is famously behind this use of the term. In this short but influential work of literary theory, he talks about the experience of watching tragic drama, which was performed by male citizens at public religious festivals in outdoor theaters across ancient Greek cities. A good tragic drama, he explains, “enables the catharsis of pity and fear” for its audience.
Commentators have spent centuries trying to decipher this statement. Is Aristotle saying that the tragedy provokes pity and fear and then dispels these very emotions? Or is it that tragedy purifies the audience of the pity and fear that they already feel, as if getting rid of something that causes trouble if it lingers in the body? And even if we settle this question, what are we to make of “catharsis” itself? It isn’t used in a sense like this in any other text. Aristotle promises us that he will explain what he means by the term in his work on tragic dramas, but that work does not survive.
Image: Bust of Aristotle. Marble, Roman copy after a Greek bronze original by Lysippos from 330 BC. Ludovisi Collection. Public Domain.
Image: Theater of Dionysus at Athens. dronepicr - Athen Akropolis. CC BY 2.0.
the word “catharsis” meant “purification,” and it could be accomplished through sacrifice or burning fragrant substances, as well as by the more literal act of washing
The traditional interpretation of Aristotle’s reference to “catharsis” in the Poetics is that it must be a religious (or quasi-religious) process. Greek tragedy was performed at religious festivals as part of a competitive display by male citizens. In ancient Mediterranean culture, as is common cross-culturally, sacred rites had a lot to do with cleansing and purifying people, spaces, and objects. In a religious context, the word “catharsis” meant “purification,” and it could be accomplished through sacrifice or burning fragrant substances, as well as by the more literal act of washing.
It may well be that when Aristotle says that a good tragedy will “enable the catharsis of pity and fear,” he is using the idea of sanctification—ritually cleansing a space of impurities—to help the reader understand the effect that tragedy (which is after all a sacred rite) has on the audience’s bodies and emotions. Whether we should understand this as analogical (tragedy acts like religious purification) or as literal (tragedy purifies the emotions in preparation for sacred rites) is up for debate.
So runs the traditional account.
In 1857, the German classicist Jacob Bernays proposed a different interpretation. Bernays argued that we should instead understand Aristotelian “catharsis” through analogy to the use of the term, as well as its related verb katheirein (“to purify”), in the medical texts of the Hippocratic Corpus. Hippocratic writers use purification terms such as katharsis and kathairein to describe the purgation of excess, corrupt, or blocked humors from the body, through blood-letting, for example, or forced vomiting. From this vantage point, tragic catharsis looks a lot like a medical procedure carried out on a city’s population to ensure emotional health and balance. Given that ancient philosophy understood emotions and desires to be potentially kinds of sicknesses (pathē or passions), Bernays’s interpretation is a compelling one. Perhaps Aristotle, son of a physician, considered tragic drama to be a public health measure all along.
It is this interpretation that seems to have influenced the husband of Bernays’ niece, a neurologist named Sigmund Freud, who, together with his associate Breuer and their patient Anna O, pioneered a new cure for hysteria, which Anna O called a “talking cure,” but which her physicians titled the “Cathartic Method.” Like tragic drama, the Cathartic Method sought to transform emotional imbalance through narrative and performance (although the transformation, in psychoanalysis, was of course thought to apply to the narrator and performer rather than to the audience); like Hippocratic katharsis, the Cathartic Method sought to release blockages through the expulsion of toxic material, such as hidden memories of childhood abuse, which carried with them repressed emotions and desires.
Image: Sigmund Freud by Max Halberstadt, c. 1921. Public Domain.
The Cathartic Method borrowed the Aristotelian idea that narrative and performance might positively transform an individual’s emotional state but took its theoretical structure from the notion of purgation as described in Hippocratic medical texts. This is likely because of Freud’s own deep interest in ancient Greece (“Oedipus Complex,” anyone?) and his familiarity with the work of Bernays as his wife’s uncle.
When we think about emotional catharsis, then, we are remembering Aristotle inflected through Freud. That’s one of the reasons that we tend to think of catharsis both as good for our mental health (rather than, say, our ritual purity) and as bound up with the act of crying. Cry it out, we say, as though it were possible to release difficult emotions and bodily fluids in the same action. (As some have argued that it is.)
Bernays’ interpretation of Aristotle has never been fully accepted. One reason is that it implies that Aristotle thought that the entire population was unwell. A medical procedure, at least within Western biomedicine, presumes a pathology. Is Bernays arguing that Aristotle thought that every audience member had some kind of emotional disorder? This seems improbable at best.
Yet, if Bernays’ reading of Aristotle is—on these grounds—unconvincing, it is also uncannily prescient. The question of how and when emotional experiences become pathologized (that is, treated as a sickness) is a burning one in modern American culture, where profit has motivated the massive expansion of the psychopharmaceutical industry and where accessing medical insurance requires the diagnosis of a pathological condition. Deciding whether our inner psychological lives are difficult or actually diseased has its knotted roots in the debate about whether Aristotle considered the “catharsis of pity and fear” to be a medical procedure.
Subsequent attempts to resolve this particular challenge to Bernays have further complicated the development of catharsis as a modern psychological concept. One such adjustment was proposed in the latter half of the twentieth century: perhaps catharsis was not to be understood so much as a medical intervention as a matter of regular hygiene. Just as we are instructed to brush our teeth twice a day, so Aristotle might have been implying that the regular expulsion of pity and fear is essential to maintaining a healthy emotional state. The key argument for this interpretation drew on another particular usage of the term katharsis, or more accurately the plural katharseis, in Hippocratic medical texts.
The plural katharseis is frequently used by Hippocratic writers to mean “menstrual blood.” It can also refer to urine and other bodily fluids that have been purged, but it was the distinctive usage associated with menstruation that caught the attention of John McCumber, a literary scholar still puzzling through Aristotelian catharsis. Perhaps, he argued, the “catharsis of pity and fear” was supposed to be imagined like the menstrual cycle: a regular, healthy process that sometimes warranted medical attention, especially if the menses were perceived to be blocked up. And indeed, any quick survey of Hippocratic gynecological writings will reveal that blocked menstrual blood was a common theory for most illnesses associated with the uterus, and that severe illness—including what we think of as mental illness—could result.
It is striking that McCumber’s interpretation, which has become widespread, seems to be lurking in the background of Freud’s appropriation of the term catharsis from Aristotle, via Bernays. The Cathartic Method was intended to cure “hysteria,” an illness with its own complicated history of medical and literary permutations, but one that, if you look it up in any common guidebook, is said to have its origins in ancient Greek gynecology and perhaps some relation to the Wandering Womb. The word “hysteria,” while it does not relate to a specific ancient disease, comes from the Greek word ὑστέρα (hystera), meaning “uterus.”
Image: Group of similar age votive uteri from Italy. From left to right: Votive uterus, wrinkled, terracotta, Italy. Science Museum Group.
© The Board of Trustees of the Science Museum, London.
The plural katharseis is frequently used by Hippocratic writers to mean “menstrual blood.”
McCumber’s idea—that Aristotle imagines tragic drama as enacting a type of public menstruation for the polis on the model of Hippocratic gynecological theory—seems almost confirmed by Freud’s repurposing of Aristotle and Hippocrates via Bernays. Perhaps McCumber was influenced by Freud’s connection of Aristotelian catharsis (a term associated with masculinity, since only men could perform in tragic drama) with (pseudo-)Hippocratic hysteria (a term associated with femininity and with menstruation). Or perhaps our own reading of Freud has been reshaped by McCumber’s identification of catharsis with menstruation.
It’s certainly the case that undergoing psychoanalysis was, and remains, feminized. With the exception of occasional spikes in interest in the PTSD of combat veterans, going to therapy (indeed, talking about emotions at all) has been cast as a feminine activity. It’s for this reason that the memoirist Melissa Febos, in an essay about trauma writing, argues that when people denigrate “cathartic” writing, “they are picturing women.” McCumber’s interpretation of Aristotelian catharsis as Hippocratic katharseis (“menstrual blood”) seems influenced by the feminization of catharsis as both a medical and a literary pursuit in modern US culture. Yet, at the same time, the feminization of emotional disorder in modern, Western culture is a product of the long history of treating the feminized body as softer, leakier, and more porous—a history that is clearly visible in Hippocratic writings. Which came first? The feminisation of emotions, the feminisation of leakiness, or the idea that emotions might be imagined as fluids moving within and out of the body?
The influence of ancient Greek medicine on modern medical practice and ideas is not a linear or a one-way passage. There’s a looping effect and an entanglement between ancient and modern approaches to healthcare—and between modern medicine and our perceptions of ancient medicine—what it was, what it meant, who carried it out, how it felt, and what effects it might have. There is no simple story to tell about the relationship between past and present, but when we pay close attention to how our present habits and ideas respond to (ideas about) the past, we can begin to see our own norms and expectations within a wider frame. In particular, and this is what I personally think is most important, we can begin to ask better—more incisive, more critical, more self-reflective—questions.
There’s a looping effect and an entanglement between ancient and modern approaches to healthcare—and between modern medicine and our perceptions of ancient medicine—what it was, what it meant, who carried it out, how it felt, and what effects it might have.
The interpretation of Aristotelian catharsis as a kind of menstruation has proved useful for drawing to the surface hidden assumptions and stories about the relationship between gender, the body, and emotional wellbeing. In particular, it highlights the way that both emotional expression and menstruation are linked to ideas of femininity through the notion of "dirt." However, the focus on menstruation as the material manifestation of catharsis is essentializing and—from a historical perspective—unnecessary, and it demands critical re-examination.
For one thing, identifying catharsis with menstruation reinforces existing ideas that to suffer emotional disorder is to be excessively womanly, and that to be a woman is to menstruate. Our ways of thinking about emotional disorder and mental illness in general are indeed closely tied to our ideas about gender, but I don’t find it helpful to tie that relationship to menstruation. Especially in the UK, where I currently reside, the insistence on menstruation as the calling-card of womanhood is a cornerstone of anti-trans rhetoric. As feminist and queer analyses have shown, the construction of menstruation as an essential component of "womanhood," inflected with both psychological and spiritual tones, excludes and does material harm to people who are genderqueer. A queer investigation of catharsis and how it ties together ideas about mental illness and gender requires a critique of the assumption that catharsis and katharseis must refer to menstrual blood.
If we return to the Hippocratic texts, we find discussion of all kinds of cyclical purgation of excess fluids—menstruation being only one, marked example—such as the regular absorption of fluid into the brain before its expulsion through the eyes, nose, mouth, and sutures in the skull. Importantly, blockage of any of these processes of the accumulation and dispersal of fluid causes illness, and blockage of this process in the brain leads (as described famously in the Hippocratic text On the Sacred Disease) to insanity, as well as (tangentially) to depression and shame. Another Hippocratic text, On Glands, describes the function of the glands as being to absorb excess fluid from the body and the brain as the biggest of the glands. When it releases the fluid it absorbs in an unhealthy way, conditions such as the Sacred Disease can result; when it retains the fluid, it can drive the person mad.
It is the brain—both in Hippocratic medicine and in modern psychotherapy—that must undergo constant, cyclical catharsis in order to avoid the build-up of the stuff it absorbs.
We might easily reimagine Bernays’ and McCumber’s interpretations of Aristotelian catharsis through this Hippocratic lens, taking the brain rather than the womb as the center of cyclical, non-pathological catharsis. It is the brain—both in Hippocratic medicine and in modern psychotherapy—that must undergo constant, cyclical catharsis in order to avoid the build-up of the stuff it absorbs.
Would this interpretive move allow for a more accurate interpretation of Aristotle and Hippocrates? Or of Bernays? Of Freud? Probably not. Centering the brain, after all, still privileges current, Western ideas about mental illness and psychological experience.
The value of tweaking our imaginary Hippocratic genealogy of catharsis lies rather in the light it might shed on our own concepts and stories: both catharsis and the fundamental role it plays in modern psychotherapy and trauma, and also the broader relationship between gender, mental illness, and the metaphor of emotions as fluids that need to be cleansed.
Catharsis is a concept deeply rooted in expert and lay approaches to mental health. It structures how people in the modern West think about their emotions and emotional disorder, and it guides their approach to treating emotional difficulties. It carries complex gender associations, being linked historically both to ritual performances by citizen men and to the treatment of hysteria in women. It has become part of the package of beliefs about women’s bodies as containers for children, for blood(lines), and for collective emotional experience, prone to rupture and to leakage, soft in ways that are both necessary and unvalued. These beliefs both constrain the lives of people assigned to womanhood and also contribute to excluding trans women, especially insofar as they rely on the elision of emotional and menstrual leakiness. We can better understand the gendered quality of emotional disorder—the ways in which feeling and feeling too much or in the wrong way is feminized within Western cultural frameworks—if we shift our attention away from catharsis-as-menstruation to the history of the concept and the meanings it has accrued.
Aristotle, Poetics (a more recent English translation by Malcolm Heath is available through Penguin, 1996)
Bernays, J. and Rudnytsky, P.L. (translator). (2004). "On Catharsis: From Fundamentals of Aristotle's Lost Essay on the 'Effect of Tragedy' (1857)," American Imago 61(3), pp. 319–341.
Breuer, J. and Freud, S. (1895). Studien über Hysterie (Studies on Hysteria). Fischer-Taschenbuch Verlag. (The English translation by Alix Strachey and Alan Tyson, originally published by Hogarth Press in 1955, is available here.)
Bobel, C. (2010). New Blood. Third-wave Feminism and the Politics of Menstruation. New Brunswick, NJ: Rutgers University Press.
Carson, A. (1990). "Putting Her in Her Place: Women, Dirt, and Desire," in Halperin, D.M., Winkler, J.J., and Zeitlin, F. (eds), Before Sexuality: The Construction of Erotic Experience in the Ancient Greek World. Princeton, NJ: Princeton University Press.
Frank, S.E. (2020). "Queering Menstruation: Trans and Non-Binary Identity and Body Politics," Sociological Inquiry 90(2), pp. 371–404.
Gilman, S.L., King, H., Porter R., Rousseau, G.S., and Showalter, E. (1993). Hysteria Beyond Freud. Berkeley: University of California Press.
Hasson, K.A. (2016). "Not a 'Real' Period? Social and Material Constructions of Menstruation," Gender and Society 30(6), pp. 958–983.
Lear, J. (1988). "Katharsis," Phronesis 33(3), pp. 297–326.
McCoy, M.B. (2013). "Tragedy, Katharsis, and Community in Aristotle's Poetics," in Wounded Heroes: Vulnerability as a Virtue in Ancient Greek Literature and Philosophy. Oxford: Oxford University Press.
McCumber, J. (1988). "Aristotelian Catharsis and the Purgation of Women," Diacritics 18(4), pp.57– 63.
Porter, J.I. (2015). "Jacob Bernays and the Catharsis of Modernity," in Billings, J. and Leonard, M. (eds) Tragedy and the Idea of Modernity. Oxford: Oxford University Press, pp. 14–41.
Scheff, T.J. (1979). Catharsis in Healing, Ritual, and Drama. Berkeley, CA: University of California Press.
What ways do you use the term “catharsis” or “cathartic,” and what types of behaviors tends to be described this way? Do they fit Aristotle’s definition? Hippocrates? Freuds? Something else?
Where does the concept of “purification” appear in todays heath landscape? What about “cleansing”? Do these overlap with other types of “purity”? What types of things are considered toxins?
If our reading of Aristotle is mediated by Freud, which relies on Hippocrates, which may have influenced Aristotle, how should we start examining ancient concepts? Is there even a place to start?
Does it surprise you that medical terminology may have influenced interpretations of Greek tragedy, or that religious terminology influenced medical conceptions? Can you think of any other vocabulary that appears both in medical and non-medical contexts?
Is it useful to think about expelling harmful humors as types of menstruation or to see menstruation as part of a broader humoral framework? What does this do the polarisation of male and female bodies?
