Medical sectarianism in the first century BCE: Alexandria (and Satellites)

Any discussion of ancient medical sectarianism must begin with the Empeirikē hairesis, the Empiric sect. It was the departure of Philinus of Cos from ‘the house of Herophilus’ (the great Hellenistic anatomist, and Philinus’ teacher), his development of a new approach to the medical art, founded solely on experience (however complexly conceived) and not on speculative theories about the workings of the human body, which started everything moving.⁶ Not that epistemological debates had been absent from previous medical discourse, but from this moment in early Ptolemaic Alexandria onwards they took on a new significance, as one group decided to base their identity on their position in this debate: to focus on related questions about the nature of knowledge and the nature of the medical art (iatrikē technē). Thus the sources repeatedly insist that these physicians ‘call themselves Empirics, from “experience” (empeiria)’; they refuse to be named after a man, as the Herophileans or Erasistrateans (the followers of Erasistratus, the other great physician of early Hellenistic Alexandria), but want to be known ‘by their frame of mind’.⁷

There is then a certain unevenness in the sectarian terrain from the very outset. Philinus’ successor as key shaper of Empiricist doctrine, Serapion of Alexandria, composed a treatise Against the Sects (Pros tas haireseis), which presumably treated all the medical lineages which were named after their founders as haireseis, despite the sense in which they were formed on quite different terms from the Empiric sect.⁸ But what the Herophileans and Erasistrateans (and, indeed, others) shared, however implicitly, was a commitment to the use of reason in medicine, to enquiries into the causes of diseases, and physiological theorizing; so, by default, they were given the collective label ‘rationalist sect’ (logikē hairesis). But, as Heinrich von Staden has emphasized, this is a purely conceptual category, useful for structuring lists of important medical figures, and setting out certain debates in a clear fashion; it is not a self-definition, nor an actual organization.⁹ Indeed, in general, the unambiguous sectarian lines drawn in later handbooks and, most especially, Galen's far from disinterested discussions of the differences between various groupings need to be treated with caution.¹⁰

The development of the eponymous haireseis themselves seems, moreover, to be a product of Hellenistic Alexandria, if not of the particular pressures of the Empeirikoi. Thus the teachers of Herophilus and Erasistratus – Praxagoras of Cos and Chrysippus of Cnidus respectively – belong to a previous era in this regard.¹¹ They are prominent physicians of the late fourth century who made a considerable impact with their writing and teaching (probably located in their home cities), formulated important theories and had influential pupils, but, it appears, were not in the business of founding long-term lineages.¹² Thus, neither Herophilus nor Erasistratus is considered a defector in any sense, indeed both are doctrinally dependent on their teachers – Herophilus shares Praxagoras’ fundamental humoralism and Erasistratus develops Chrysippus’ distinctive opposition to therapeutic bloodletting.¹³ Rather they inaugurate a new phase in the nature of medical groupings. These figures, together with Erasistratus’ brother Cleophantus, will not just have students, but also followers for generations to come.¹⁴ They will provide points of identification; essential parts of their teaching will continue to command allegiance, long after both their deaths and the demise of those who studied with them, as some kind of pedagogic continuity and collective identity is maintained down the centuries.

Still, all these haireseis are pretty loose genetic formations, based on a mixture of shared doctrine and descent, without any formal organization. Ptolemaic Alexandria became a centre of learned medical activity, including education. It was a place where Herophilean, Erasistratean and Empiric teachers could be found, as well as those with no apparent affiliation; but it was not the location of an Empiric or Herophilean School. At any one time there might have been a particularly pre-eminent figure operating in a specific current or field, but there is no indication that any kind of pedagogic monopoly or sectarian scholarchy attended on such a position; and eminence was just as often shared, or indistinct, in any generation. Nor, in fact, did studying with a Herophilean, or anyone else, necessarily determine the allegiance of a student, who might indeed have shopped around for his learning. There is a certain presumption in that direction, however, a sense that being the auditor (Greek akoustēs) or discipulus (Greek mathētēs) of someone – which is a relationship the ancient sources are certainly interested in – implies a degree of doctrinal continuity, of sectarian succession, unless otherwise stated. Still, things might well turn out otherwise and, in a world without formal leadership or organisation, there can really be no orthodoxy either. The followers of Herophilus may all have agreed with their founding father that sphygmology was an important part of the medical art, for instance, but they all offered their own, slightly different, definition of the pulse and developed its study in diverse ways. And there are greater disagreements too, noted between followers, or between founder and followers, and noted without particular excitement.¹⁵

All of these issues, and more, are illustrated in the Empeirikē hairesis of the first century bce; for the most prominent Empiric physician of that century (probably of any century) followed a career path not unlike that of the sect's founder: Heracleides of Tarentum was a pupil of the Herophilean Mantias before switching allegiance.¹⁶ Despite his fame as a pharmacologist, Mantias’ dates are not known, nor indeed his location; though there is a strong Alexandrian presumption in all of this.¹⁷ Generally, if a Herophilean left Alexandria it was noted, and no such notice appears for either Mantias or Heracleides. Heracleides is also a little more datable since he reuses a remedy belonging to the Erasistratean Hicesius, whose activities are mentioned by Strabo (in an interesting passage which will be discussed below) and placed ‘in the time of our fathers’; that is about 100 bce.¹⁸ All the other chronological hints and relations pertaining to Heracleides tend to prevent his moving too far away from Hicesius, so Alessia Guardasole (as Karl Deichgräber before her) concludes that his floruit is most likely to be around 75 bce.¹⁹

Heracleides’ departure from Mantias appears to have been less hostile than Philinus’ from Herophilus, though, for he seems to have taken both strong pharmacological interests and some slightly rationalist ideas with him. The late antique, and far from Empiric, Latin medical writer Caelius Aurelianus even accuses Heracleides of failing to observe the ‘custom’ (‘mos’) of his secta, by advocating a therapeutics which depended, in part, on notions of disease causation.²⁰ Galen, on the other hand, allows Heracleides to defend himself from any charges of un-Empiric conduct in relation to his discussion of the vexed question of whether or not a dislocated hip can ever be successfully reset. Heracleides’ view, which Galen quotes in order to agree with it, is that it can be, as a range of distinguished witnesses and his own experience testify.²¹ From this it follows, he says, and in response to a Herophilean argument for impossibility on anatomical grounds, that sometimes the tendon which keeps the hip bone in place does not snap completely, despite the dislocation, but rather loosens and can tighten up again.²² Having thus ventured into possibly enemy terrain and become involved in speculation about hidden processes, Heracleides concludes that ‘to enquire into these things is useful, though not entirely universal (koinon)’.²³ Galen explains that the Tarentine added this to protect his empiricist principles, though he is less helpful on exactly how it achieved that.

Whether Heracleides’ statement here, embedded as it was in a work on therapeutics, should simply be taken as clarificatory, or whether his Empiric credentials were being called into question at the time is entirely unclear.²⁴ Against exactly whom any defence might have been offered would also make a considerable difference. Being called inconsistent, or contradictory, by external rivals is one thing, indeed a very common thing in ancient medical discourse, but it would be quite another, unparalleled in fact, if an internal rival were to accuse a fellow-sectarian of not being a ‘real Empiric’ (or ‘real Herophilean’ or the like).

Heracleides certainly does seem to have had at least one contemporary internal rival. Apollonius of Citium is the author of the only text to survive from the incredibly vigorous and productive medical scene in Hellenistic Alexandria – that is, his so-called commentary on the Hippocratic treatise On Joints – and it is a text which evinces an Empiricist position, albeit rather more subtly than some would like.²⁵ Apollonius never refers to himself explicitly as an Empeirikos but, in discussing the question of resetting the hip, he lays out the positions of those who argue from anatomy and those who argue from experience, the latter being the view he himself clearly favours; indeed his exposition is more strictly Empiric than that of Heracleides.²⁶ On this occasion Apollonius made no mention of the Tarentine, but he also wrote eighteen books against Heracleides’ Hippocratic lexicography and three books against the first of such glossaries, that of the Herophilean Bacchius.²⁷ Though Hippocratic interpretation of various kinds was certainly an important activity for the Alexandrian Empeirikoi (from Philinus onwards), as also for the Herophileans, and both groups wished to claim the authority of the great man, there is no indication that Apollonius was doing anything other than asserting himself in the genre in the customary manner – that is by attacking and replacing the most recent work in the area (belonging to Heracleides in this instance) – rather than anything more systematic or sectarian.²⁸ So, this looks more like the Herophilean debates about the pulse than anything more serious; ancient medicine was, after all, a competitive business, and differentiation from, and contest with, rival physicians was just a part of the way things worked. The arguments within rather than across sectarian boundaries were of a distinct kind, but they were no less lively and committed for that.

Apollonius, unlike Heracleides, seems to have had an Empiricist teacher – Zopyrus of Alexandria.²⁹ Zopyrus is not labelled as an Empiric in any surviving source, his name appearing in no extant list of prominent Empeirikoi, but what little is known about him is perfectly congruent with Empiricism, so his allegiance is inferred from that of Apollonius. As well as probable doctrinal continuity between the two, there is a certain continuity of orientation towards royalty. Apollonius dedicated his Hippocratic commentary to King Ptolemy, and the guess is, given that he is a contemporary, perhaps a younger contemporary, of Heracleides, that this is Ptolemy Auletes (or Neos Dionysios), who ruled most of what remained of the Ptolemaic Empire from 80 to 51 bce (though he was briefly deposed in 58–55 bce), or his brother, Ptolemy of Cyprus, king of the other part of the imperial domains from 80 to 58 bce.³⁰ Zopyrus is reported by Celsus to have concocted an antidote for King Ptolemy, perhaps Auletes again, or one of his longer-lasting predecessors (Soter II or Alexander I); and by Galen to have sent a similar recipe to Mithridates VI Eupator – the culturally and territorially ambitious King of Pontus – carried by a condemned man on whom it was intended to be tested (once he had been poisoned, of course).³¹

Given Mithridates’ famous interest in both medicine and poisons, this story is probably too good to be true, unless Zopyrus was a court physician and this was essentially a diplomatic mission.³² He might, though, have been a more ordinary participant in Mithridates’ network of medical patronage and correspondence, or at least have aspired in that direction; and the tale, with or without its embellishments, serves to confirm Zopyrus as an older contemporary of Heracleides.³³ Mithridates did not die until 63 bce (and then with some difficulty), having been King of Pontus for some sixty years, but his medical activity is likely to have reached its heights in his most expansionist, empire-building phase, in the couple of decades before the outbreak of the first war with Rome in 88 bce; though there is no reason to think it then came to a complete halt.

Roman power was also being felt quite acutely in Egypt at this time: the whole Mediterranean world was being reconfigured politically and culturally in the first century bce. So it is perhaps unsurprising that Apollonius of Citium seems to bring the Hellenistic, Alexandrian, phase of the Empeirikē hairesis to an end. There are a couple more Empiric physicians plausibly located in the mid first century, but after that the record becomes largely blank.³⁴ Deichgräber's attempts to bridge the gap between Apollonius and the revival of a more sceptical medical empiricism in the early second century ce are ingenious but not convincing.³⁵ There is only one figure of any solidity in this period – Cassius – and, whether or not he was an Empiric, and whether his career began in the first century bce or later, he was definitely based in Rome, not Alexandria.³⁶ This was now the place to be.

There are some parallel developments within the ‘rationalist’ community of the first century bce, in terms of the shifting geography of learned medicine. The emergence of Rome as a real centre of medical culture in this century, a story which is very much bound up with the crucial and controversial career of the great ‘rationalist’ physician already mentioned, Asclepiades of Bithynia, will, however, be deferred for the time being, while we complete the consideration of the various other, more Alexandrian, reconfigurations of the period. In this respect, Strabo reports that in his time a ‘great school (didaskaleion) of Herophilean physicians’ was founded in the vicinity of the temple of Men Karou, near Laodicea in Phrygia, by Zeuxis, just as in the previous generation Hicesius established an Erasistratean school at Smyrna.³⁷ It appears that the institution at Men Karou was somewhat more successful than that at Smyrna, however. Hicesius had followers, but no known heirs; while Zeuxis had been succeeded by Alexander Philalethes by the time Strabo was writing, and he was then perhaps followed by Demosthenes Philalethes in the first century ce.³⁸ Regardless of longevity, these moves seem to mark a new development in ancient medical organization. Strabo's use of the term didaskaleion is striking, as is his explicit assertion that these are Herophilean and Erasistratean schools respectively. A monopoly situation seems to be envisaged, within an exclusively pedagogical context, involving scholarchs; which is all rather different from the Alexandrian set-up and looks in some ways closer to the philosophical model.

Whether such monopolistic considerations played any part in motivating these moves is entirely unclear, however. Both Herophileans and Erasistrateans continued to be active in Alexandria at the same time, and along much the same lines as before. The Herophilean Dioscorides Phacas may have been associated with the Ptolemaic court of Auletes and his warring children, Cleopatra VII and Ptolemy Theos Philopater, for example, while his younger contemporary, Apollonius Mys, is one of the most famous and influential followers of Herophilus more generally.³⁹ Apollonius, indeed, lived through the final defeat of Cleopatra (and Antony), and Egypt's annexation by Rome, entailing as it did Alexandria's absorption into a new international order and thus her political, if not yet cultural, eclipse. The names of Erasistrateans who can be securely located in first-century bce Alexandria are rather harder to come by, but the current actually seems to have been collectively more robust than the individually better-populated Herophilean grouping. The Erasistrateioi are the strongest corporate presence in the first-century ce compilation by Anonymus Londinensis, for example, and they were a successful and distinct presence in Galen's Rome, while the Herophilean lineage had dissolved over a century earlier.⁴⁰

Doctrinal divisions between the Herophileans of Men Karou and those of Alexandria are equally elusive. It has been suggested that Alexander Philalethes was a pupil of Asclepiades of Bithynia, though the only source to assert this is very late and the practicalities are problematic; but he is certainly associated with Asclepiades and Asclepiadean ideas more widely, giving his Herophileanism a particular flavour.⁴¹ One of his pupils, Aristoxenus, seems to have been a very contentious character, moreover, whose substantial treatise, On the Sect of Herophilus (Pēri tēs Hērophilou haireseōs), criticized pretty much all its members, though von Staden suggests that his fellow-Laodiceans may have been spared.⁴² This is speculation, however, and Aristoxenus could also be described as following a trend set by the Alexandrian Herophileans Apollonius Mys and Heracleides of Erythrae, both probably slightly older than him, in composing such a text, focused on his own sect.⁴³ All may be demonstrating a degree of insecurity about their own sectarian identity, and concern about the diminishing strength of Alexandria in an increasingly competitive cultural environment, medicine included; a world in which some of the terms of the medical debate are shifting. The old epistemological battle lines are being redrawn, or indeed erased, in favour of more generally systematic ones, in which competing versions of the medical art make greater use of a range of philosophical concepts and approaches to system building.

The key figure in driving this change forward, in breaking up the old Hellenistic medical settlement, is Asclepiades of Bithynia. It is he who puts Rome on the map of ancient medical learning, who finds this growing Mediterranean metropolis a location conducive to the development and propagation of a new, more joined-up and theoretically elaborated style of medical system. This is a style which engages with Hellenistic epistemological debates and other dividing lines but also moves beyond them and takes the tradition in a different direction. So it is to Rome that our discussion must now turn. Before making that move, however, Antiochus must be fitted into the narrative, one which has some more general parallels with the contemporary story of philosophical decentralization too.

While much remains uncertain about Antiochus, it is undoubtedly the case that Alexandria's medical scene, and wider cultural situation, made it a relatively easy place for him to find an appropriate audience, one that would be receptive to a new doctrinal direction, less judgemental and more flexible about matters of school allegiance and identity than was normal in Athens. Heracleides was about to leave his Herophilean teacher for the Empiric sect, for example, apparently without recrimination, and he, like all around him, would continue to claim Hippocratic authority for his version of the medical art. It is worth noting here that Alexandria is also where Aenesidemus established his new philosophical circle.⁴⁴ Moreover, while Antiochus’ relationship with Lucullus complicates the picture, the facts that he did not go to Rome when forced out of Athens, that open hostilities with Philo broke out when Philo was in Rome and Antiochus in Alexandria and that the dispute could be thought to express the wider animosity between the two cities are surely significant. Without Lucullus’ presence, it is assumed that Ptolemy Soter II might well have sided with Mithridates and, regardless of royal manoeuvring, Alexandrian sympathies are likely to have been largely anti-Roman, particularly among intellectual circles.⁴⁵ Rome was not just a political threat but, increasingly, a cultural rival too. The medical haireseis of Alexandria may have had outposts in Smyrna and Laodicea, but not Rome, and Zopyrus corresponded with Mithridates, not the Senate: it was the Battle of Actium in 31 bce which finally broke Alexandrian resistance in this respect.⁴⁶ So, however accidental the circumstances, Antiochus’ travels, both his departure from Athens and his sojourn in Alexandria, did probably play a role in his doctrinal development, in fostering his distinct position and his own claim to the legacy of Plato.

Medical sectarianism in the first century BCE: ROME (and Satellites)

Meanwhile, Asclepiades had been having a major impact on the medical scene in Rome, as is evinced by the privileged position he occupies in all the surviving Latin medical texts of the early empire: that is, those of Celsus, Scribonius Largus and Pliny the Elder. The value each places on the Bithynian physician's intervention varies, but all these authors give him the decisive role in determining the shape and substance of learned medicine in Rome thereafter, which they are all responding to, engaging with, in their own ways. He made a more general impact on the classical medical tradition too, one which can be traced across most of its textual remains, including its more summary compilations – its handbooks and catechisms.⁴⁷ Indeed, Asclepiades also features in more philosophically oriented doxographies, as well as being recognized for his commitment to the philosophical enterprise by Antiochus of Ascalon himself, as mentioned at the outset.

The more local Roman evidence seems the best place to start, however. In the summary history of ancient medicine which forms part of his proemium to the books on the medical art, Celsus describes developments as petering out, and a dull inertia setting in, as the division between rationalists and empiricists became well established and congealed: ‘until Asclepiades changed, in large measure, the approach (rationem) to healing’.⁴⁸ It is, then, Asclepiades and his most famous but divergent pupil, Themison, whom Celsus casts as the founders of modern medicine; it is they who have shaped the medical art of the present day, as reflected in his text.⁴⁹ Scribonius Largus, in the dedicatory epistle which commends his collection of recipes to the imperial freedman Callistius, refers to Asclepiades as ‘the greatest medical authority’, though one whose position on pharmacology was rather underdeveloped, and so vulnerable to being traduced.⁵⁰ The Bithynian physician's first appearance in the Natural History is just as laudatory. Asclepiades is hailed as the ‘most outstanding’ (‘summa’) figure ever in the art of medicine, outstripping even Hippocrates himself.⁵¹ Though it counts amongst his achievements at this point, however, it will turn out that founding a ‘new sect’ (‘nova secta’) is actually not a good thing to do; and the numerous innovations which Asclepiades introduced into the medical culture at Rome, the large-scale changes he wrought, will be lambasted in the rest of the work. Asclepiades is the chief villain in Pliny's Roman medical history, a fact that emphasizes, rather than diminishes, his impact.

It is his ‘new sect’ that is of most interest here, of course, but before we examine its formation in more detail, questions about Asclepiades’ dates must be addressed. For, in an important article, Elizabeth Rawson argued that the Bithynian was more a figure of the late second than early first century bce, and her chronology has been very widely accepted.⁵² It is, however, questionable, for she puts far too much pressure on a single, somewhat ambiguous, sentence of Cicero's On the Orator; and she rejects the reasonably substantial conflicting evidence (such as that of Sextus) pretty much out of hand. The fact that Cicero has the great orator L. Licinius Crassus say, in a dialogue set in 91 bce, that ‘we have been familiar’ with Asclepiades, ‘as physician and friend’, while praising his rhetorical skills and noting the medical success they have brought, certainly means that the Bithynian was well established in Rome by this date, having already gained the respect of cultured Roman aristocrats; but it does not mean that Asclepiades was already dead by that juncture.⁵³ Despite Cicero's historical punctiliousness in his dialogues, they are also literary products, after all; and, even if Crassus is taken to be definitely asserting that familiarity with the Bithynian had completely ceased at this point, his demise is not the only possible, or indeed most plausible, explanation of that situation.

That Asclepiades has left town may be unlikely, and Cicero would probably have reported a serious quarrel but perhaps not something less dramatic: what if the Bithynian had simply withdrawn from Crassus’ circle to pursue other projects? Like Galen, several centuries later, Asclepiades may have moved on from an initial phase of frenetic self-promotion, of chasing elite patients and patrons and of ‘surpassing the other physicians in eloquence’, to a period of intellectual consolidation and system-building. He may have turned from public performance and the cultivation of the smoothest of bedside manners to gathering a circle of pupils around him and putting his vision of the medical art into writing. This is, after all, what is involved in founding a ‘new sect’, and these are activities which neither Crassus nor any of his other conversationalists make any reference to at all.⁵⁴ Pliny may be quite loose in his use of the term ‘secta’, which he takes to be synonymous with ‘factio’ and ‘schola’, but it is clear that he means a grouping with a distinct identity, comprising adherents to particular doctrines, and all owing allegiance to their eponymous hero.⁵⁵ It is also clear, from that and other evidence, that this was a Rome-centred phenomenon; the imperial capital was where Asclepiades had his greatest intellectual impact, where his lineage really flourished.⁵⁶ So, while Pliny's temporal framing, which places the Bithynian ‘in the time’ (‘aetate’) of Pompey the Great, pushes things too far forward, Sextus’ synchrony of Antiochus and Asclepiades may have more to it.⁵⁷ Probably an older contemporary of the philosopher, the Bithynian physician certainly arrived in Rome before the end of the second century bce, but he is also likely to have lived into the second decade of the first century, perhaps long enough to see the young Pompey's rise to fame as Sullan partisan in 83 bce. This would give Asclepiades the time in Rome necessary to have the kind of impact that he did and would produce the most plausible relative chronology for his various pupils and followers, and for the ‘new sect’ he founds.

Four physicians are specifically labelled in the sources as the Bithynian's pupils (auditores = Greek akoustai; or discipuli), and not just as his followers (sectatores or Asklēpiadeioi). They are Themison of Laodicea, Titus Aufidius the Sicilian, Philonides of Dyrrachium, and Nico of Agrigentum.⁵⁸ Of these, all except perhaps Themison, whose eventual defection will be discussed below, clearly participated in Roman networks of influence, power and status. They hailed from either Sicily or Rome's main bridgehead to the east, and Titus was even a Roman citizen.⁵⁹ Others were to follow in his footsteps. In addition to Marcus Artorius, Octavian's physician, and the freedman Antonius Musa, who famously cured Augustus with cold baths in 23 bce, both of whom seem to have been Asclepiadeans, two of the most significant pharmacological authorities of the mid first century ce are the Asklēpiadeioi Sextius Niger and Tullius Bassus.⁶⁰ This sectarian label is applied to them by Dioscorides, the most influential writer on medical materials of that century, and Pliny cites both as authorities for most of the medical books in the Natural History, making explicit what would otherwise have to be surmised: these were Romans who wrote in Greek.⁶¹ Dioscorides lists other affiliates of what he considers to be the dominant current in his field too, including a Petronius, who would seem to be Roman by birth or manumission, as do the Marcus Gallus, Clodius and perhaps Lucius who are referred to as Asclepiadeans in other sources.⁶²

Dioscorides, a non-sectarian author of a specialist medical treatise, also identifies the doctrinal signature of the Asklēpiadeioi in much the same way as encyclopaedic summarizers and compilers of medical handbooks will. It is their commitment to a particulate physics which is crucial: their commitment to a conception of the human body as composed from onkoi (corpuscles) and poroi (pores or passages); and to a definition of health as balance (summetria) of the onkoi and poroi, and disease as caused by the impaction (entasis) of the former in the latter.⁶³ This, of course, also informs their therapeutics. Galen repeatedly brands Asclepiades ‘shameless’ for his rejection of a specific humoral approach, indeed of any kind of qualitative approach to curative regimes and prescriptions altogether.⁶⁴ Others found more appealing the notion of ‘general remedies’ (or ‘aids’) – such as abstaining from or drinking wine or water, fasting, massage and various forms of ‘passive exercise’ (for example, rocking) – which emerged from Asclepiades’ ideas about how human bodies interact with their environment – how somatic composition and balance are affected.⁶⁵ Celsus adapts an Asclepiadean pattern in parts of his exposition, and Pliny views the seductive simplicity and pleasantness of these therapies as the secret of the Bithynian's success amongst the Roman elite.⁶⁶

The encompassing and integrated character of Asclepiades’ medical system is thus clear. His views obviously had epistemological dimensions too, and, as well as the implicit commitment to reason as the basis of his version of the iatrikē technē, the Bithynian is cast by Galen as openly despising experience more generally: as a vocal, though contradictory, opponent of reliance on it in medicine and, it follows, hostile to the Empeirikē hairesis.⁶⁷ This does not seem to be Asclepiades’ main concern, however. He was more positively focused on his systematic and joined-up approach to medicine and on promoting its innovative qualities: on the newness of his prescriptions and therapies, and the way they fitted into a larger set of understandings and explanations.⁶⁸ The novelty may have worn off, but his many followers certainly stuck to his main teachings and remained committed to a physiology, pathology and therapeutics based on onkoi and poroi – on the body's particulate situation, processes, and interactions. And they did so with continuing success, as has already been illustrated, in respect of both the prominence of their patients and their wider contribution to the intellectual and practical portions of the medical enterprise.⁶⁹

Doctrinal continuity seems to have been maintained, in part, through systematic exegesis of Asclepiades’ writings. Medical pedagogy was to become increasingly bound up with commentary, the detailed explication of a set of texts, and it appears that this was the Asclepiadean practice from early on. Caelius Aurelianus (following Soranus) has Asclepiades’ sectatores picking over his statements word by word, and Pliny makes a rather vague reference to close study, examination, of Ascelepiades’ famous book The Wine-Giver (Oinodotes).⁷⁰ This suggests some kind of institutional framework, presumably located in Rome, though there is no reason to suppose that that was the only place where the teachings of Asclepiades might be engaged with; nor should the formality of any such set-up be exaggerated. The list of followers or adherents is a relatively long one but it lacks scholarchs, or even leaders; and, indeed, specified master–pupil relationships are absent after the first generation. Rawson agrees that the physician Sextus Fadius, whom Cicero encounters in Velia in 44 bce, is the pupil of Nico of Agrigentum, though neither his teacher's ethnic nor his sectarian affiliation is specified.⁷¹ Artorius or Antonius Musa would be similarly second- or third-generation Asclepiadeans, but all the other physicians so labelled float more freely in time, occupying a space somewhere after Asclepiades and before the date of the treatises in which they appear. The vitality of the Asclepiadean lineage through the first century bce and well into the first century ce is apparent none the less, as is its focus on Rome, although there are numerous Greek names as well as Roman amongst its adherents.⁷²

The nova secta that Asclepiades founded is, therefore, new in both form and content, not to mention location. The geography and cultural flavour of learned medicine is shifting, aligning itself more closely with the changing patterns of political power. So it is perhaps unsurprising that the main challenge to Asclepiadean dominance at Rome should come from within, from the defection of Asclepiades’ pupil Themison of Laodicea and the establishment of a rival medical grouping by his followers, based on a particular ‘method’ (methodos). It is in this direction that this discussion will now turn.

A passage in Pliny has Themison initially loyal, adding to his teacher's writings, and then subsequently changing his doctrines (‘decreta’).⁷³ Celsus considered this divergence to have occurred very late in life – in senectute.⁷⁴ Caelius Aurelianus’ ongoing engagement with both master and pupil presents a similar pattern of continuity, collaboration and then departure but from a different perspective.⁷⁵ While for Pliny Themison's move is symptomatic of a wider malaise in the world of Greek medicine, as its factionalism, instability, disagreements and changeability all count heavily against it, for Celsus it is more progressive but still generically so.⁷⁶ It is not that Celsus actually favours the Laodicean physician's teachings, the methodos he and his followers propound, but that he has a broadly positive view of change, new ideas, in the medical tradition in general. Recent developments, as he sees it, have pushed matters forward, adding to the medical resources he can call on in compiling his encyclopaedia today. For Caelius, on the other hand, Themison's defection is a very specific step in the right direction, towards the true ‘method’, and the formation of the sect with which he himself identifies.⁷⁷ There is still considerable work to be done: Thessalus of Tralles and (most especially) Soranus of Ephesus, whose treatise Caelius is ‘Latinizing’, will need to complete the job in the first century ce; but they are building on Themison's foundations and, indeed, owe much to Asclepiades too.⁷⁸

Still, Celsus, writing a couple of decades before Thessalus’ arrival on the Roman medical scene, speaks of the followers (‘aemuli’) of Themison as a distinct grouping, as a self-identified, definite presence in contemporary medical culture.⁷⁹ He locates them in the context of the epistemological debates between the champions of reason and those of experience, and as asserting their distance from both.⁸⁰ According to Celsus, they held that causes are irrelevant to therapy, all that is required being to grasp the ‘generalities’ (‘communia’) of disease: its division into ‘constricted’ (‘adstrictum’), ‘fluid’ (‘fluens’), and ‘mixed’ (‘mixtum’) varieties. Recognition of these types, whether the conditions are acute or chronic, and of their phases, leads to the appropriate therapeutic conclusions. They call this path, or process, ‘the method’ (methodos in Greek) and have built their sectarian identity around it. Thus, they disagree with both the notion that medicine is a matter of ‘conjecture about hidden things’ (‘coniectura rerum latentium’), and the view that it is a matter of ‘studying experience’ (‘observatione experimentorum’). Having set up this double rejection, however, Celsus goes on to undermine its validity.⁸¹ Themison's followers must, in fact, be relying on reason or experience in the construction of their method, and on their commitment to it; and they have impoverished these two possibilities, these two approaches, through their denials and misunderstandings. Excluding the benefits of causal considerations, on the one hand, and the detailed differentiation of diseases, cases and circumstances, on the other, is unhelpful and is not what actually happens anyway.

Celsus’ project in all this is pretty clear, for his own position emerges through this discussion as roughly the mirror image of the one he gives to Themison's aemuli: that is, an acceptance of the contribution of both reason and experience, generality and particularity, to the medical art, in a properly balanced combination.⁸² His reportage is, therefore, undoubtedly rather contrived, and quite different from that of Soranus and Caelius Aurelianus, for example. Though consistently critical of Themison's Asclepiadeanism, these authors never represent his moves towards the true ‘method’ in epistemological terms, and they rarely deploy traditional (or Hellenistic) sectarian terms more generally.⁸³ There is little sense of a really radical break at any level, either between Asclepiades and Themison or between the latter and his successors; rather there is a rolling programme of therapeutic reform. Caelius catalogues and corrects numerous curative errors, in which the occasional conceptual misprision is of no more significance than the much more frequent mistakes of practical detail, of timing and technique, of prescription and process.⁸⁴

Alongside the regular engagement with the man himself, Caelius also repeatedly refers to Themison's secta and sectatores.⁸⁵ Indeed, he mentions two followers by name – Eudemus and Proclus – and reports, praises and criticizes their views on a number of medical matters.⁸⁶ Though the only figure explicitly labelled as Themison's student (mathētēs) is Meges of Sidon (by a scholiast on Oribasius), the assumption has been that both Proclus and Eudemus were his pupils, not just adherents: students, indeed, of his old age, because, unlike Meges, they appear in various listings of Methodikoi.⁸⁷ This is all rather speculative, however, and attempting to construct a lineage of Themisonians, or early Methodics, is impossible given the partial and contradictory nature of the evidence. Some texts tend to confirm the closeness of Themison, Proclus and Eudemus, others refute it, and many are entirely indifferent.⁸⁸ All that can be said with certainty is that Themison did found a distinct medical grouping in the mid first century bce, which seems to have been centred on Rome and formed according to the new style;⁸⁹ that is, on terms which could be construed epistemologically but do not seem to have been presented that way by their instigator. His followers might have been more inclined to discourse on reason and experience; but, while Celsus may be right to say that ‘through their name’ (‘eo nomine’) they registered their dissent from the partisans of both, on the assumption that the name in question is ‘Methodics’ (or, at least something based on methodos), this dissent could be more thoroughgoing than he allows.⁹⁰ It might be less concerned with rejecting speculation about hidden causes or observation than with rejecting both as routes to intellectual identity, asserting instead that they should be defined in a more processual way, through their whole approach to the aims of the art of medicine.

It is not just Asclepiades and Themison in Rome who are ringing in the changes at this juncture, breaking up the old Hellenistic medical settlement, for there is another, less easily localized but just as distinctive, medical current which arrives on the scene in the first century bce. The Pneumatikē hairesis, a grouping within the ‘rationalist’ fold which is named not from its founder or its ‘frame of mind’ or ‘method’ but from its commitment to the ‘all-pervading pneuma’ as the underlying cause of both health and disease.⁹¹ This is just one of the notions that Athenaeus of Attaleia, the inaugural Pneumatikos, took from the Stoics, for he was, according to the surviving Arabic translation of Galen's treatise On Containing Causes, ‘a pupil’ (tilmîd) of Posidonius.⁹² The Latin version is less specific in its phrasing but certainly places Athenaeus and Posidonius in a direct and personal relationship.⁹³ The obvious place for the Attaleian physician to have studied with Posidonius is Rhodes, and the indications are that this was in the latter stages of Posidonius’ career, but where Athenaeus then lived, practised, wrote and taught is entirely obscure. He might have stayed on Rhodes, or moved to Alexandria or to another city of the Greek East or even, though this seems the least likely, have visited Rome. If Athenaeus had spent time in the imperial capital then he and his followers would not have escaped Celsus’ notice, as they did, whereas recent medical developments outside the metropolis are basically ignored by the encyclopaedist. It is a few decades after Celsus was writing that the Pneumatikoi make a splash at Rome, with Agathinus the Spartan and his even more famous pupil, Archigenes of Apamea; and Agathinus seems to have made a conscious effort at relaunching the ‘pneumatic’ brand of medicine.⁹⁴

Though the Pneumatikoi do not seem to have made the most propitiously located of starts, then, Athenaeus did have students, one of whom – Theodorus – is named by Diogenes Laertius, and a ‘Magnus’ also comes between the original founder and Agathinus.⁹⁵ What Athenaeus also had was a systematic and theoretically developed approach to the medical art, which seems to have been contained in a single thirty-book work, Peri boēthēmatōn, from which only fragments survive.⁹⁶ It covered elemental physics and general principles of causation, as well as human physiology and pathology – the causes and classifications of disease – regimen and therapeutics. Galen has nothing but admiration for the scope and coherence of Athenaeus’ vision, for his rigour and thoroughness, and his construction of an entire medical system, though he often strongly disagrees with the actual content (or, at least, claims he does).⁹⁷ He also notes that Athenaeus engaged with, and argued against, Asclepiades’ elemental theories, which not only would tend to confirm the Attaleian as a figure of the mid rather than early first century bce but also emphasizes the equivalence between the two men's medical projects.⁹⁸

These are both systems built around the application of certain kinds of physics to medicine, to understanding the human body in sickness and health, and to the movement between the two. These physics come as part of wider packages, moreover: they fit into larger philosophical structures. The sense of buying into the whole package may be more direct and obvious for Athenaeus in relation to the Stoics than for Asclepiades in relation to the Epicureans, and much scholarly energy has been expended on trying to distance the Bithynian from contemporary atomism; but it is still there none the less.⁹⁹ David Leith has recently and persuasively argued for a closer connection between Asclepiades and Epicurus than has been fashionable lately, and there is a broader point of systematicity too.¹⁰⁰ Theoretical reach and coherence, practical completeness and explanatory continuity have all become important features of the way in which sectarian identities are formed in the medical world of the first century bce, in line with other intellectual developments of the period, well exemplified by Antiochus’ new philosophical system. Again reminiscent of Antiochus, epistemology has been integrated into these more encompassing approaches, rather than making the running; and there is a sense in which Themison's ‘method’ could be seen as a more compact, pared down, version of this same project.

This is, of course, to argue that a primary characteristic of the changing shape of medical sectarianism in the late Hellenistic period is a growing philosophical influence on medicine or, to be more precise, a greater impact of certain philosophical schools on medicine, rather than vice versa.¹⁰¹ However, these more philosophically sophisticated medical currents could then contribute to, and become more involved in, discussions within and between the various philosophical formations, as Antiochus registers with his reference to Asclepiades’ views on sensation and perception. The importance of location and connection has also been emphasized in this increasingly Rome-centred world. Being in Rome itself is more important for the medical men than for the philosophers at this point, but both benefit from association with the Roman aristocracy. The key source for the elite relations of Antiochus and Asclepiades, however, namely Cicero, again underlines the distinction between the two. He makes only a single reference to the Bithynian physician, to his persuasiveness and success, but without any medical content, which stands in stark contrast to his much more substantial discursive engagement with Antiochus. This is far more expansive, and with real content, actual exploration of his teaching, involving a larger cast, a larger set of ideas and a larger stage. The relative position of philosophy and medicine, with the former being something that a Roman senator might himself practise and the latter something he will get others to practise for him, is thus writ large. Still, these aristocratic entanglements were advantageous in both cases, strengthening as they did Antiochus’ and Asclepiades’ claims to authority and leadership in their own fields.

Conclusion

There is then a sense in which medicine and philosophy converged in the late Hellenistic world. The philosophical schools moved a little closer to the medical haireseis in their configuration and meaning, with the new/old foundations of Antiochus and Aenesidemus, and a greater degree of mobility between groupings more generally; while the figures really setting the pace in the medical domain are those who have finally adopted the programme of the Hellenistic philosophical schools and have built coherent medical systems on philosophical models. Antiochus’ gesture towards contemporary medical thought, preserved by Sextus Empiricus, could be seen as recognizing that growing philosophical sophistication amongst some leading physicians. However, though much of this movement, on both sides, fits in with wider patterns of change in the late Hellenistic Mediterranean, little actual interaction between medicine and philosophy has been detected beyond the general traffic in ideas. Moreover, while some of the geopolitical factors at work have had similar effects across the board, others have impacted in a more differentiated way, reinforcing the divergent social and political positions of medicine and philosophy, and underlining their distinct organizational principles.

So, for example, while the metropolitan strongholds of philosophy and medicine – Athens and Alexandria respectively – are both damaged and displaced by the rise of Roman power, and by the conflicts and alliances implicated in that rise, there are elements of commonality and difference in the stories which play out as a result. On the one hand, that decentralization fosters greater variation in approach and allows for more innovation (however framed) is a point of general validity; on the other hand, Athens and Alexandria are quite distinct cities, with quite distinct metropolitan claims, so that much else will diverge. Whereas Athens’ grip on philosophy is historical and ideological and has already survived its political fall, Alexandria's grip on medicine is rather more pragmatic. The Egyptian capital will find enough of a history to be able to rebuild itself as the premier, though far from exclusive, centre of medical education in the early Roman Empire, after its power has definitely departed, but with that political loss will go its ability to keep hold of the most medically ambitious. These physicians will, by and large, move on from Alexandria to Rome; for unlike the philosophers, who can expect sections of the Roman elite to come to them, physicians have to go to their patients, and, for the time being, their aristocratic interactions will be mainly by the bedside or at least have the bedside in fairly direct view.¹⁰²

Antiochus and Asclepiades demonstrate these differences despite their dialogue. Antiochus will return to again-defeated Athens to teach and will have Roman senators as students; Asclepiades will stay in victorious Rome but will not count senators amongst his pupils, and, though it is necessary to construe the category of patient pretty broadly to encompass his relations with Crassus, that does seem to be the correct category none the less.¹⁰³ Moreover, while without a school identity of some kind a philosopher would find students hard to come by (indeed, it might be argued that in the ancient world just being a philosopher, without a school, is existentially tricky), the same cannot be said of physicians in search of patients. Claiming to have studied in Alexandria or to be an Asclepiadean or the like will have assisted in the process of self-marketing, especially to the elite, but it was not essential, and other aspects of the presentation took priority. Certainly, just being a physician, without further affiliation, was not only a viable possibility but also a very common one, even amongst those operating in the learned medical tradition. For all could go back to Hippocrates and lay claim to his authority; sectarian divisions in medicine came later and, however elaborate, were less fundamental than in philosophy. Antiochus, on the other hand, rather emphasizes the fundamental quality of the philosophical schools.