King Saul's mysterious malady

Gillian P. Williams; Magdel le Roux

Department of Old Testament and Ancient Near Eastern Studies, University of South Africa

Correspondence to

This article investigates the 'illness' of King Saul (as narrated in the Old Testament). The 'anti-Saul narrative' states that 'God's spirit had left Saul' and 'an evil one had taken its place' (1 Sm 16:14; also cf. e.g. of his behaviour in 1 Sm 19:24; 1 Sm 18:28-29). The latter years of Saul's reign were marred by his pre-occupation with David's growing popularity. He eventually became mentally unstable and suspected everyone of plotting against him. Saul's battle against the Ammonites, as well as his last battle against the Philistines at Mount Gilboa, was fraught with difficulty. It is postulated that Saul experienced epileptic-like fits and assumedly suffered from some kind of 'depression' as a result of post-traumatic stress disorder (cf. 1 Sm 18:9; 1 Sm 18:28, 29; 1 Sm 19:24). This was possibly exacerbated by the enemy herem principle. Talmudic and other perspectives were also provided in the article where possible.

Introduction

According to the Old Testament narrative, King Saul, the first king of Israel,¹ who reigned in Jerusalem from c.1029-1005 BCE (Oded 2007:78) was the son of the wealthy and influential Kish from the tribe of Benjamin (1 Sm 9:1). An enigmatic figure, he was chosen by God to be the first King of Israel in response to the people's request (1 Sm 8:5), although this was contrary to the old theocratic ideal that God alone was King of Israel (1 Sm 8:22). Saul's kingdom was a confederacy of states rather than a united kingdom, with their capital at Gibeah, 6 km north of Jerusalem (Boshoff, Scheffler & Spangenberg 2000:77). Myers (1962a:232) is convinced that Saul's supporters were the tribes of Benjamin, Ephraim and Manasseh (2 Sm 2:8-9). It is tragic that, according to the narrative, Saul's son, Ishbosheth, was later murdered by two of his own kinsmen - Baanah and Rechab (2 Sm 4:7).

An examination of the description of the period of Saul's rule in 1 Samuel discloses a complex literary situation (Amit 2000a:171; cf. Dell 2008:80-83). Apparently, two versions of Saul's life are combined in the book of Samuel - one pro-Saul and the other anti-Saul.² The pro-Saul version, probably written first (Boshoff et al. 2000:82), was in favour of the monarch, believing that he was a brave and humane king who was later rejected by God (1 Sm 15:26) in favour of another (1 Sm 15:28) and that one of his sons should reign after him. Ishbosheth, the sole survivor of the battle of Mount Gilboa, did reign (Boshoff et al. 2000:82), but was assassinated, as mentioned above. Carson et al. (1995:306, 308) believe that Saul was appointed king because Israel needed a strong and united government that would be able to maintain security throughout the kingdom.

Saul's military talent was evident when he received God's support and, according to the narrative, re-assembled the Israelite tribes to crush the Ammonites (1 Sm 11:11; according to the pro-Saul version). Saul fought many battles - against the Moabites, the Edomites and kings of Zobah, but the Philistines were his greatest challenge and posed the most serious and constant threat to Israel. The pro-Saul camp believe that Saul was regarded as a sort of charismatic prophet or judge-king by his people (1 Sm 10:11; Boshoff et al. 2000:83; cf. Siegman 1967:1096; Bright 1972:185; Amit 2000a:171-175).

During the last years that Saul was on the throne, he was very pre-occupied with David's increasing fame which severely depressed him (1 Sm 18:9, 28, 29; Carson et al. 1995:314). The anti-Saul narrative stated that Saul had lost God's spirit and an evil one had replaced it (1 Sm 16:14; also cf. e.g. of his behaviour in 1 Sm 19:24). He eventually became mentally unstable and suspected everyone of plotting against him (Siegman 1967:1096). Saul's last battle against the Philistines at Mount Gilboa was fraught with difficulty (1 Sm 28). The distinction between the two spirits, 'the spirit of the Lord' and 'the evil spirit from the Lord' supports the explicit positions in the polemic (Amit 2000a:172). The reader of this text needs to distinguish between the Saul who is good in the eyes of the Lord and the one who, as a result of his behaviour, has lost favour.

The purpose of this article is not to provide an intensive exegesis of the different passages, neither is it to determine the historicity of the Saul narratives. Rather, its aim is to contribute towards the understanding of the possible cause of the 'condition' (or 'bad behaviour') of Saul as suggested in 1 Samuel.

Saul's mental state

Saul's 'epileptic-like fits'

Epilepsy is defined as 'a neurological disorder involving recurring temporary loss of consciousness with or without convulsions, muscular spasms or automatic movements' (Coulson et al. 1980:282). During an attack the patient often falls down (Anderson [1968]:385), shouts or cries out (cf. 1 Sm 19:23), becomes unconscious and falls to the floor, whilst the body goes into severe muscular spasms. The patient usually sleeps for several hours afterwards (1 Sm 19:24). Anderson ([1968]:385) states that the cause of epilepsy is unknown but he is certain that it is the abnormal discharge of electrical currents in the brain. Berkow and Talbot (1977:1404) maintain that it is caused by birth trauma or a metabolic disorder. Brain tumours, whether benign or cancerous, can also cause epileptic-type seizures in all patients (Simon 2006).

Rosner (1978:299), a doctor and medical historian, suggests that Saul 'may have had frequent epileptic seizures', which are also termed 'convulsive disorders' (Berkow & Talbott 1977:1404). He justifies his viewpoint with reference to 1 Samuel 19:24: Saul had followed the messengers to Naioth. 'And he also stripped off his clothes and he also prophesied before Samuel, and lay down naked all that day and all that night ...' (1 Sm 19:24). Carson et al. (1995:315) understand the word 'prophesy' to mean 'an abnormal trance-like state', which concurs with the views of Rosner (1978:229).

If Saul (as described in the biblical narrative) had some kind of epilepsy it is possible that such a condition may have been caused by a brain tumour or a tumour on or inside his cranium. The description of his behaviour in 1 Samuel 19:24 is, to a certain extent, reminiscent of an epileptic fit. However, it is perplexing that Saul ruled for about 34 years, yet he only suffered one such episode (as depicted in the Bible). If this character had been suffering from a brain tumour, he would have had many more such episodes with the progression of the disease (Berkow & Talbott 1977:1437-1438).

Saul's 'depression' and 'post-traumatic stress disorder'

Post-traumatic stress disorder (PTSD)³ is the name given to a psychiatric disorder caused by partaking in, or experiencing, traumatic events. The symptoms, according to Young (1988:203), would include: images and nightmares of the trauma as the original event is 're-played', depression and anxiety, insomnia and waking up at night screaming.

Young (1988:204) explains that events which cause severe trauma are usually those acts which are contrary to good or sound morals. During combat, troops fight for their lives and kill the enemy in a sort of 'autopilot mode' without internalising the seriousness of their acts, enabling a numbness of moral responsibility to set in at that time (Young 1988:208). Examples of this would be the slaughter of innocent women and children in a combat situation, which Saul was commanded by God to carry out (1 Sm 11:6-11). He also witnessed King Agag of the Amalekites being hacked to pieces by the prophet Samuel (1 Sm 15:33). Young does not mention King Saul at all, but when the principles of PTSD are being applied to assess Saul's condition according to his stress situations (as they appear in 1 Samuel), the application appears to be relevant to Saul's situation.

The other classic symptoms of PTSD - the nightmares and waking up screaming - are not mentioned in the Old Testament. However, it is mentioned that Saul flew into jealous rages and ranted (1 Sm 18:10) and although the Bible does not mention at what time of day or frequency this took place, it could well be regarded as part of his possible PTSD.

As stated above, King Saul's PTSD was most probably exacerbated by the ancient Israelite's adherence to the principle of herem.⁴ This principle is translated as 'forfeited property' (Alcalay 1990:826), where forbidden people or things are sacrificed to God. Greenberg (2007:10) maintains that the category of herem applicable in this case is Israelites who worship other gods. This would include groups or individuals, their idols and objects of worship. The total destruction of the enemy was regarded as an act of homage to God, whilst the Israelite troops were merely God's assistants (Jdg 5:23). Dunn and Rogerson (2003:224) agree that this sacrifice was regarded as a type of burnt offering to God because it usually took the form of a conflagration destroying the entire population, their livestock, crops and dwellings.⁵ Greenberg (2007:11), though, is convinced that there are too few incidents to state that herem was a general rule of ancient Israelite warfare.

The lives of most people in ancient times were very stressful, especially those of kings, who were expected to judge (2 Sm 15:2), rule in a morally correct way (2 Sm 23:3), obey the law (1 Ki 2:3), formulate law (Dn 3:29), and declare war and give pardon (1 Sm 11:5-11; 2 Sm 14:1-11). Most of 1 Samuel narrates Saul's gradual mental decline, including Saul's later symptoms of re-active depression, paranoia, hysteria, violence and mood swings (Young 1988:196). Because Saul had witnessed atrocities in battle, possibly even been part of them, the chances are that he had suffered from PTSD. The attack on the Amalekites in the city of Amalek, where Saul was instructed by God to annihilate an entire people, their possessions and livestock (1 Sm 15:3), comes to mind as an example of one such trauma.

Biblical perspectives on the life of Saul

Saul's condition and the stress of his royal responsibilities

Besides the traumas of war, one cannot help but wonder whether Saul really wanted to become king. He was not ambitious - he was appointed by God without a choice in the matter (Carson et al. 1995:305). The way he hid behind the supplies at Mizpah (1 Sm 10:22) is clearly part of the anti-Saul narrative, which caused some to question his willingness to reign (1 Sm 10:27). Dunn and Rogerson (2003:219) are unsure whether Saul's hiding demonstrates mere modesty or a character flaw. Sanford (1985:26-27), however, believes that Saul was ego-centric and had run away from a situation which he perceived was a threat to him; he was too insecure within himself to handle the heavy responsibilities of kingship. Green (2003:43), a Biblical historian, agrees with this point of view and observes that Saul was uncomfortable and hesitant. This was borne out by the fact that after being proclaimed king at Mizpah, Saul returned home. Carson et al. (1995:307) maintain that everyone went home, including Saul, who was, for a time, dependent on his farm for a living because a taxation system was not yet in place at the beginning of the monarchy. Green (2003:40), on the other hand, feels that this was done to escape his royal responsibilities.

The narratives in the Old Testament tell us how the spirit of God boosted Saul's kingly self-confidence and enabled the real royal personality of Saul to manifest, replacing all his insecurities (Sanford 1985:30) in such a way that he led Israel to victory (1 Sm 11:11) against the Ammonites (1 Sm 11:4) and the Philistines. Dunn and Rogerson (2003:220) refer to this as a 'God - Saul transfer' which won the day (this was most probably written by the pro-Saul supporters).

The relationship between Saul and the prophet Samuel

Samuel was opposed to kingship; he regarded God as his only king because his own mother, Hannah, had dedicated him to God in answer to her prayer for a child (1 Sm 1:27). Although the people demanded a king (1 Sm 12:3, 18), Samuel was still determined to continue to wield power over Israel through Saul (1 Sm 12:22-25; cf. Oded 2007:79). Green (2003:46) emphasises that there was no kingly mentor from whom Saul could learn. If Saul had been supported by a more sympathetic prophet such as Nathan, his story may have been a more positive one (Myers 1962a:232; cf. Boshoff et al. 2000:77).

The love-hate relationship between Saul and David

The love-hate relationship that Saul experienced with David warrants some attention. At first Saul welcomed David into his domain: initially as a musician to heal his dark moods - and grew very fond of him in the process (1 Sm 16:21-23) - then, as a champion 'giant-killer', he joined Saul's army (1 Sm 17:51; 18:5). Saul became very jealous of David's fame and feared that he would become the next king (1 Sm 18:9). 'But when Saul saw and knew that the Lord was with David ... Saul was still more afraid of David. So Saul was David's enemy continually' (1 Sm 18:28-29). From this stage onward there begins a long period of suffering, during which Saul behaves like a man pursued, suspecting those who are closest to him. At about that time, Samuel had secretly anointed David as the next king. Although his act had been sanctioned by God, it was still fraught with treason and deceit; Samuel had to ensure that Saul never found out (1 Sm 16:1-13; Carson et al. 1995:313; Amit 2000a:175). Clearly these chapters were penned by the anti-Saul narrators.

Saul and the medium at Endor

Because God had not answered his pleas for help and guidance before the battle, Saul then committed an 'unthinkable act' - he consulted a medium at Endor, contravening his own edicts in the process for he had banished all soothsayers from Israel (1 Sm 28:9). The medium got in touch with the spirit of the dead Samuel, who was angry at being disturbed (1 Sm 28:15-16). Samuel's message to Saul was that both he and his sons would die during the battle and Israel would be defeated.⁶ This was confirmation of Saul's worst anxieties (1 Sm 28:19), which could explain his 'heroic' suicide, (so called by the pro-Saul authors), before his inevitable capture at Mount Gilboa. He did not want his body to be dishonoured by the Philistines, his enemies (1 Sm 31:4).

It is ironic that, in his despair, Saul broke the law by consulting a banned medium. Sorcery, which included soothsaying, divining, necromancy and casting spells, was contrary to God's holy law (Rosner 2000:287; Dt 18:9-14). Witchcraft was outlawed and those found guilty were killed (Ex 22:18). This incident merely confirms Saul's depressed state of mind at his rejection by God (Carson et al. 1995:319; Dunn & Rogerson 2003:228). Saul was convinced that he saw Samuel and heard what he most feared - that he was doomed to die⁷ (1 Sm 28:19; Carson et al. 1995:319; cf. Dunn & Rogerson 2003:228). However, Rosner's (1978:313) view is that Saul did not actually see the ghost of Samuel at Endor, but presumed it was the old prophet from the description of his garb as provided by the medium.

Saul's fear of capture by the Philistines during his final battle was justified. He fell on his sword and committed suicide (1 Sm 31:5) rather than be taken prisoner and humiliated by the Philistines (1 Sm 31:4 - pro-Saul version; Boshoff et al. 2000:83). Rosner (1978:312) finds Saul's behaviour understandable in view of the emotive circumstances. Nevertheless, it is uncertain why Saul's bones were burnt; Carson et al. (1995:320) suggest that it was meant to honour the bodies of the king and his sons and to prevent abuse of them at the hands of the Philistine victors (1 Sm 31:9-10 - pro-Saul version?). Dunn and Rogerson (2003:229), however, believe that this passage is part of the anti-Saul narrative because burning was regarded as desecration of the body.

Possible remedies during biblical times

Sanford (1985:65) notes that the king's courtiers did not summon a doctor to treat Saul's illness, although there must have been well-trained physicians in Israel as there were in Greece, for instance. Yet, no mention is made of herbalists or herbal medications. The reason for this was that the prophets, who had a special relationship with God, were spiritual leaders not healers and regarded illnesses as coming from God - healing also would come only from God through prayer (Sanford 1985:66).

Archaeological perspectives

There are few archaeological skeletal remains available in Israel because Jewish religious law (halakhah) views the grave of a deceased as sacred and any skeletal remains discovered in the course of an archaeological dig have to be re-buried as fast as possible (Greeff 2005:84). This religious belief unfortunately does not encourage scientific examination of any remains found (Greeff 2005:85) because the type of testing that can be performed on such remains is also restricted (2005:84). Autopsies were similarly forbidden by the Talmud as they would dishonour the deceased (Talmud - Baba Bathra 155b; cf. Rosner 2000:35; Dell 2008:87-88).⁸

Although the Talmudic⁹ sages were very pro-Saul, there is surprisingly little Talmudic material available on Saul's 'condition'. Rosner (2000:115) believes that Saul may have suffered from epilepsy¹⁰ based on the words 'fallen down' in 1 Samuel 19:24. Moses Maimonides (cited in Rosner 2000:184) interprets this as referring to kordiakos¹¹ , as discussed in the Mishnah when a man suffering from delirium requests a bill of divorce for his wife (Mishnah - Gittin 7:1). If Saul had been an epileptic (nikpheh - literally meaning 'one who writhes' - Rosner 1978:300), then the rabbis believed that his disorder may have been caused by: indecent behaviour during cohabitation (the nature of which is not clarified), or standing naked in front of a lit lamp. Cohabitation by lamplight would also result in an epileptic child, and the same applied when a child younger than one year lay at the foot of the cohabitants (Talmud - Pesachim 112b), whilst cohabitation immediately after defecation (Talmud - Gittin 70a) and blood-letting also resulted in the birth of a child afflicted with epilepsy (Midrash - Leviticus Rabbah 16:1). There is no mention in the Talmud that Saul suffered from melancholy¹² , although remedies were prescribed for this condition.

A decoction of Wild rue (Ruta graveolens) plant was recommended by Dioscorides¹³ (3:52) for epilepsy. This plant is native to the Mediterranean region and Daniel (2006:77) also documents its modern anti-epileptic use (cf. 1984:270). The seeds of the Chaste Tree (Agnes castus vitex; Dioscorides 1:135) would be applied to the body generally as a poultice with oil and vinegar to remedy epilepsy. Chiej (1984:157) believes that a branch of the Chaste Tree would be hung over a doorway to discourage evil spirits in ancient times but provides no further information in this regard.

A Midrashic remedy for epilepsy would include being cared for by a suitable physician (Leviticus Rabbah 26:5). The Talmud refers to depression as 'melancholy' or 'heaviness of heart' and the sages said that this problem would be treated by eating three barley cakes topped with a Persian milk sauce (Talmud - Gittin 69a) or consuming dates (Talmud - Kethuboth 10b). The use of amulets for healing was also permitted according to halakhah (Jewish religious law), as long as idolatry was not involved. Wearing the image of a pagan god was prohibited, although it was regarded as superstitious, rather than heretical, if the patient believed that it was therapeutic (Rosner 1978:147). The rabbis recommended the use of 'approved'¹⁴ amulets for medical purposes to ward off or to treat epileptic fits, although they could not be displayed in the street because that was forbidden as idolatry (Talmud - Shabbath 61a). Those worn around the neck had to be hidden underneath the clothing of the patient. Two types were permitted: an amulet consisting of parchment with words of the Torah written across it, or an amulet of herbs, as is the practice in African cultures today.

Conclusion

The story of Saul as portrayed in the pages of the Old Testament is a complex one. It is difficult to give an objective opinion, if at all, on Saul's condition because the narrative is fraught with the subjective tension between the pro-Saul and anti-Saul camps. If an unbiased view can be gleaned from the polarised writings, it would be that Saul was king for about 34 years and that he fulfilled the peoples' need for a king to stand up for them against the Amalekite, Ammonite and Philistine threats (Oded 2007:78). Most of his reign was characterised by freedom from conscription and taxation. At Gilgal (1 Sm 11:12-13) 'he was again proclaimed king and portrayed as a magnanimous person who spared the life of his foes' (Scheffler 2001:67). War was fought by volunteers and funds were made available by donations received (Siegman 1967:1096). His reign was largely burdened with war stress and the defences of his territory.

The personality and power clash between Saul and Samuel can be explained by the probability that there was, in those times, no clear separation between 'church and state'. Saul's relationship with his son-in-law that 'he loved to hate', was difficult and it contributed to his deteriorating mental health. As such, he vented his rage onto David.

Although reluctant to rule (1 Sm 10:22), Saul won many battles and was more humane towards his enemies than many others of his time. He was a free spirit who did not accept Samuel's brutality in killing King Agag. Apparently, Saul did not seem to think and react in the way that kings of his day were expected to.

The Saul narrative clearly displays his humaneness as well as his errors of judgement. His paranoia regarding David's kingly ambitions may have initially been absurd but there must have been an intuitive side to Saul, as his fears proved to be well founded - God had indeed chosen another king, leaving Saul on the throne until 'his time was up', seemly sidelining him until his death. The incident with the spirit medium at Endor was born out of desperation. It is almost as if Saul expected confirmation that he would not win the battle of Mount Gilboa. Perhaps, in Saul's case, it was a matter of living with so much fear and negativity that his anxieties eventually became his reality and, as such, it is not surprising that he took his own life. To a certain extent Saul's suicide could be justified under the circumstances.

Archaeological evidence of skulls manifesting tumours is very sparse in Israel on account of the strict laws of halakhah, which requires that any skeletal discoveries be reburied hastily to avoid desecrating the grave. Unfortunately, this procedure does not favour acquisition of new archaeological knowledge and only certain tests can be performed on the human remains. It is very difficult in Israel for 'science' and 'religion' to co-operate in this discipline and, as such, the subject is a very contentious one.

Rosner (1978:311) is not certain that Saul suffered from a mental illness at all. His opinion is that the king was simply overwrought and terribly stressed by various events in his kingdom, particularly the guerrilla warfare with his neighbours, the Philistines; when he tried to prevent his army from deserting, he was upbraided by Samuel. He knew that his days as king were numbered, that his kingdom would be given to another and he was rejected by both Samuel and God and humiliated before his people. The Old Testament mentions symptoms which could be described as an epileptic fit (1 Sm 19:23-24), but there is mention of only one such possible episode. If he had many attacks, the Bible does not document this, nor does it mention whether Saul had any pre-existing disorders before becoming king.

It might be reasonable to conclude that Saul's mysterious malady was most likely 'depression', which was initially brought on by PTSD and was especially exacerbated by Samuel's bloody execution of King Agag (in strict compliance of the enemy herem principle) after the battle against the Amalekites.

Acknowledgements

I would like to thank the University of South Africa for the study bursary that enabled me to write the dissertation from which this article is an extract, as well as Prof. M. le Roux for her valuable assistance.

Competing interests

The authors declare that they have no financial or personal relationship(s) which may have inappropriately influenced them in writing this article.

Authors' contributions

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Correspondence to:
Magdel le Roux
Postal address: 404 Portland Place, London Road ]]> Sea Point 8005, South Africa
Email: lrouxm1@unisa.ac.za

Received: 05 July 2010
Accepted: 21 Apr. 2011
Published: 20 Jan. 2012

© 2012. The Authors. Licensee: AOSIS OpenJournals. This work is licensed under the Creative Commons Attribution License.
1. It is not within the scope of this article to deal with the issue at stake surrounding the existence of the 'state of Israel' or surrounding the persons of Saul or David.
2. Boshoff et al. (2000:82) state that the narrative of Saul in 1 Samuel contains at least two contradictory elements. 'The earlier pro-Saul and pro-monarchic narrative appears in 1 Samuel 9:1-10:16; 11; 13-14; 31' and 'the later anti-Saul and anti-monarchic narrative appears in 1 Samuel 8; 10:17-27; 12 and 15. This was most probably because the Deuteronomist who compiled the larger narrative of Deuteronomy to 2 Kings, combined the two narratives about Saul' (cf. Amit's 2000b:647-661 discussion on the significant differences of the Chronicler's presentation of King Saul, and the version in 1 Samuel & cf. Knoppers 2006:187-213). ]]> 3. The Institute for the Treatment of PTSD is part of the United States Veterans Administration Medical System and its findings were that almost all of its patients were Vietnam War veterans (Young 1988:203). The Institute's psychiatrists discovered that the veterans' emotional disorders originated because of their involvement in, or enforced observation of, war-related atrocities, such as the torture and violent killing of prisoners-of-war, civilians and their fellow Americans (Young 1988:203).
4. This means 'forbidden or to become sacred' (Greenberg 2007:10).
5. Almost similar to the so-called 'scorched earth policy' practiced by the Zulu king, Shaka, and in later times, the British during the Anglo-Boer War (Coulson et al. 1980:762).
6. Although not mentioned by Boshoff et al. (2000:83) as an anti-Saul view, these passages also depict Saul as weak and powerless.
7. This was probably part of the anti-Saul narrative, because it shows the king to be a weak and criminal character.
8. Evidence of brain tumours and other such medical conditions has been recorded in some cases where scientific examination of archaeological remains has been conducted. A simple benign bony tumour called an osteomata consists of a 'button' tumour that manifests as a small mound on the outside of the cranium on the skull and is depicted diagrammatically in Brothwell and Sandison (1967:142, Figure 54B). The remains date back to the Neolithic period. An X-ray of an adult skull excavated from Lima, Peru in 1936 displays a small tumour situated on the right side of the skull (Ortner & Putschar 1981:379). Another type of simple tumour called a compact osteoma, displays very little demarcation between the bone and the tumour itself. Some tumours of this kind, however, can appear inside the skull, where they can exert pressure on the surface of the brain leading to epilepsy (Zivanovic 1982:139).
9. Despite the fact that the Talmud is much younger than the biblical narratives, it is still valuable because it was written in order to elucidate the biblical text.
10. Also called a 'falling sickness' (Rosner 2000:184).
11. The Talmud describes this to mean 'being overcome by new wine from the vat' (Gittin 67b).
12. Described as 'habitual tendency to sadness and depression' (Coulson et al. 1980:529). ]]> 13. A physician in the Roman army during the 1st century CE.
14. An approved amulet (kemiya) was one that had healed three men simultaneously.