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Vascular Medicine: A Companion
to Braunwald's Heart Disease

THIRD EDITION

Mark A. Creager, MD
Director, Heart and Vascular Center, Dartmouth-Hitchcock Medical
Center; Professor of Medicine and Surgery, Geisel School of Medicine at
Dartmouth, Lebanon, New Hampshire

Joshua A. Beckman, MD, MS

Director, Section of Vascular Medicine, Cardiovascular Division, Vanderbilt
University Medical Center; Professor of Medicine, Vanderbilt University,
Nashville, Tennessee

Joseph Loscalzo, MD, PHD

Hersey Professor of the Theory and Practice of Medicine, Harvard Medical
School; Chairman and Physician-in-Chief, Soma Weiss, MD, Distinguished
Chair in Medicine, Department of Medicine, Brigham and Women’s
Hospital, Boston, Massachusetts
Table of Contents

Instructions for online access

Cover image

Title page

Copyright

Dedication

Contributors

Foreword

Preface

Acknowledgments

Series page
Part I: Biology of Blood Vessels

1: Vascular Embryology and Angiogenesis

Abstract
 Tunica intima: endothelium

Tunica media: smooth muscle and extracellular matrix

Tunica adventitia

Summary

2: The Endothelium

Abstract

Homeostatic functions of the endothelium

Endothelial heterogeneity

Endothelial dysfunction and vascular disease

Functional assessment of the endothelium

Conclusions

3: Vascular Smooth Muscle

Abstract

Origins of vascular smooth muscle cells during embryonic

development

Vascular smooth muscle cell phenotypic modulation

Influence of cell-cell and cell-matrix interactions

Phenotype-specific vascular smooth muscle cell functions

Inflammation and inflammation-related processes

Senescence and aging

 Conclusions

4: Normal Mechanisms of Vascular Hemostasis

Abstract

Endothelial function and platelet activation

The coagulation cascade leading to fibrin formation

Fibrinolysis

Summary

5: Vascular Pharmacology

Abstract

The pharmacological framework of drug action

Therapeutic intervention and the endothelium

Therapeutic intervention and the autonomic vascular innervation

Therapeutic intervention and the vascular media

Part II: Pathobiology of Blood Vessels

6: Pathobiology of Atherosclerosis

Abstract

Risk factors for atherosclerosis: traditional, emerging, and on

the rise

The diversity of atherosclerosis

 Atherosclerosis: a systemic disease

7: Pathobiology of Aortic Aneurysms

Abstract

Degradation of the medial extracellular matrix

Smooth muscle dysregulation

Inflammation and oxidative stress

Biomechanical stress

Risk factors and genetics of aortic aneurysms

Epigenetics/micrornas in aortic aneurysms

Conclusion

8: Pathobiology of Thrombosis

Abstract

Overview of thrombosis

Platelets, thrombosis, and vascular disease

Inflammation and thrombosis

9: Pathobiology and Assessment of Cardiovascular Fibrosis

ABSTRACT

Overview of collagen

Collagen structure, properties, and relevance to human biology

 Regulation of collagen synthesis

Regulation of collagen metabolism

Fibrosis in clinical cardiovascular disease

Myocardial fibrosis in specific cardiovascular conditions

Biomarkers of myocardial fibrosis

Targeting myocardial fibrosis

Vascular fibrosis in systemic hypertension

Vascular fibrosis in pulmonary arterial hypertension

Conclusions

10: Pathobiology of Vasculitis

Abstract

Large-vessel vasculitis

Small-vessel vasculitis

Medium-vessel vasculitis

Summary

Part III: Principles of Vascular Examination

11: The History and Physical Examination

Abstract

Vascular history
 Vascular examination

12: Vascular Laboratory Testing

Abstract

Limb pressure measurement and pulse volume recordings

Transcutaneous oximetry

Physical principles of ultrasonography

Carotid duplex ultrasound

Abdominal aorta evaluation

Renal artery duplex ultrasonography

Peripheral arterial ultrasonography

Pseudoaneurysm

Arteriovenous fistulae

Venous duplex ultrasound

Plethysmographic evaluation of venous reflux

Vascular laboratory accreditation

13: Magnetic Resonance Imaging

Abstract

Acknowledgment

Basic principles
 Magnetic resonance angiography techniques

14: Computed Tomographic Angiography

Abstract

Fundamentals of computed tomography imaging

Radiation exposure and radiation dose reduction

Emerging technologies in computed tomography

Artifacts and pitfalls of computed tomographic angiography

Clinical applications of computed tomographic angiography in

vascular disease

15: Catheter-Based Peripheral Angiography

Abstract

Imaging equipment

Radiographic contrast

Imaging technique

Obtaining vascular access

Complications of peripheral vascular angiography

Part IV: Peripheral Artery Disease

16: The Epidemiology of Peripheral Artery Disease

Abstract
 Symptoms and measures of peripheral artery disease in
epidemiology

Incidence and prevalence of peripheral artery disease

Peripheral artery disease risk factors

Interaction and risk factor comparisons

Progression of peripheral artery disease

Co-prevalence of peripheral artery disease and other

atherosclerotic disease

Peripheral artery disease as a predictor of mortality and

morbidity

17: Pathophysiology of Peripheral Artery Disease

Abstract

Clinical expressions of peripheral artery disease

Hemodynamics in peripheral artery disease

Contributors to limb symptoms in peripheral artery disease:

beyond arterial stenosis

Altered skeletal muscle structure and function in peripheral

artery disease

Summary

18: Peripheral Artery Disease: Clinical Evaluation

Abstract
 Patient history

Critical limb ischemia

Physical examination

Diagnostic testing

Summary

19: Medical Treatment of Peripheral Artery Disease

Abstract

Interventions to reduce cardiovascular risk and adverse limb

events

Interventions to improve symptoms and function

Summary and conclusion

20: Endovascular Treatment of Peripheral Artery Disease

Abstract

Patient and lesion selection criteria

Technical and procedural considerations

Clinical outcomes

Conclusions

21: Reconstructive Surgery for Peripheral Artery Disease

Abstract
 Aortoiliac occlusive disease

Infrainguinal Arterial Occlusive Disease

Part V: Renal Artery Disease

22: Pathophysiology of Renal Artery Disease

Abstract

Epidemiology of renal artery disease

Pathophysiologic consequences of renovascular disease

Renal artery disease and mortality

23: Clinical Evaluation of Renal Artery Disease

Abstract

Consequences of renal artery stenosis

Physical examination

Diagnosis of renovascular disease

24: Treatment of Renal Artery Disease

Abstract

Critical functions of the kidney

Medical therapy for renal artery disease

Fibromuscular dysplasia
 Atherosclerotic renal artery stenosis

Treatment of unusual causes of renal artery stenosis

Treatment of renal artery aneurysms

Surgical management of atherosclerotic renal artery disease

Part VI: Mesenteric Vascular Disease

25: Epidemiology and Pathophysiology of Mesenteric Vascular Disease

Abstract

Acute arterial occlusive mesenteric ischemia

Mesenteric artery dissection

Nonocclusive mesenteric ischemia

Mesenteric venous thrombosis

Chronic mesenteric ischemia

26: Clinical Evaluation and Treatment of Mesenteric Vascular Disease

Abstract

Chronic mesenteric ischemia

Acute occlusive mesenteric ischemia

Acute nonocclusive mesenteric ischemia

Mesenteric venous thrombosis

Part VII: Vasculogenic Erectile Dysfunction

27: Vasculogenic Erectile Dysfunction

Abstract

Definition and classifications

Epidemiology

Public health and clinical implications

Functional anatomy

Pathophysiology of erectile dysfunction

Evaluation of erectile dysfunction

Treatment

Longitudnal psychological outcomes

Guidelines

Part VIII: Cerebrovascular Ischemia

28: Epidemiology of Cerebrovascular Disease

Abstract

Overview

Stroke risk factors: demographic factors

Stroke risk factors: lifestyle

Medically treatable risk factors

Other risk factors

 Awareness of Stroke Warning Signs and Acute Treatment

The future

29: Clinical Presentation and Diagnosis of Cerebrovascular Disease

Abstract

Overview of clinical stroke

Clinical manifestations of stroke and cerebrovascular disease

Clinical assessment tools

Conclusions

30: Prevention and Treatment of Stroke

Abstract

Prehospital and emergency department management of

ischemic stroke

Acute stroke therapy

Secondary prevention of ischemic stroke

Primary prevention of ischemic stroke

31: Carotid Artery Revascularization

Abstract

Indications for Carotid Revascularization

Preoperative Management
 Carotid Endarterectomy

Carotid Artery Stenting

Postoperative Management

Outcomes for Carotid Endarterectomy and Carotid Artery

Stenting

Transcervical Carotid Stenting with Flow Reversal

Management of Postcarotid Endarterectomy Stenosis

Part IX: Aortic Dissection

32: Pathophysiology, Clinical Evaluation, and Medical Management of

Aortic Dissection

Abstract

Epidemiology

Classification

Pathogenesis

Predisposing Genetic Factors

Acquired Disorders

Clinical Presentation

Laboratory Testing

Diagnostic Imaging

Differential Diagnosis
 Initial Medical Treatment (Fig. 32.9)

Indications For Intervention (Box 32.5)

Prognosis

Long-Term Surveillance

33: Surgical Therapy for Aortic Dissection

Abstract

Type a Aortic Dissection

Acute Type B Aortic Dissection

Chronic Type B Aortic Dissection

Future Therapies

34: Endovascular Therapy for Aortic Dissection

Abstract

Branch Vessel Interventions

Aortic Interventions

Part X: Aortic Aneurysm

35: Epidemiology and Prognosis of Aortic Aneurysms

Abstract

The Normal Aorta

 Definition Of Aortic Aneurysm

Epidemiology And Prognosis Of Aortic Aneurysms

Inherited and Developmental Disorders

Other Conditions Associated with Aortic Aneurysm

36: Clinical Evaluation of Aortic Aneurysms

Abstract

Clinical history

Physical examination

Screening of aortic aneurysms

Surveillance of aortic aneurysms

Diagnostic testing

37: Surgical Treatment of Abdominal Aortic Aneurysms

Abstract

Definition

Decision-Making for elective abdominal aortic aneurysm repair

Rupture risk

Expansion rate

Elective operative risk

Life expectancy
 Surgical decision-Making

Preoperative assessment

Surgical treatment

Complications of abdominal aortic aneurysm repair

Functional outcome

Long-Term survival

38: Endovascular Therapy for Abdominal Aortic Aneurysm

Abstract

Indications

Anatomic requirements

Endograft design

Graft placement and postoperative management

Problems with endografting and management

Outcomes

Other considerations

Summary

Part XI: Vasculitis

39: Overview of Vasculitis

Abstract
 Classification of vasculitis

Large-vessel vasculitis

Medium-vessel vasculitis

Small-vessel vasculitis

VARIABLE-VESSEL VASCULITIS

Evaluation and diagnosis of possible vasculitis

Treatment of vasculitis

40: Large Vessel Vasculitis

Abstract

Acknowledgment

Takayasu arteritis

Giant cell arteritis

Isolated idiopathic aortitis

41: Medium and Small Vessel Vasculitis

Abstract

Medium vessel vasculitis

Small vessel vasculitis

Pauci-immune small vessel vasculitis

Immune complex mediated small vessel vasculitis

42: Thromboangiitis Obliterans (Buerger Disease)

Abstract

Epidemiology

Etiology and pathogenesis

Pathology

Clinical presentation

Differential diagnosis

Diagnosis

Prognosis

Management

Future perspectives

43: Kawasaki Disease

Abstract

Epidemiology

Etiology and pathogenesis

Pathology

Clinical presentation

Cardiac manifestations

Cardiac testing

Clinical course
 Treatment

Coronary revascularization for late stenosis

Preventive cardiology

Summary

Part XII: Acute Limb Ischemia

44: Acute Arterial Occlusion

Abstract

Epidemiology of acute limb ischemia

Etiology of acute limb ischemia

Pathophysiology of acute limb ischemia

Diagnosis of acute limb ischemia

Treatment of acute limb ischemia

45: Atheroembolism

Abstract

Pathobiology

Etiology

Atheroembolic syndromes

General treatment measures for atheroembolic disease

prevention
 Conclusions

Part XIII: Vasospasm and Other Related Vascular

Diseases

46: Raynaud Phenomenon

Abstract

Overview of primary raynaud phenomenon

Pathophysiology

Secondary Causes of Raynaud Phenomenon

Diagnostic tests

Treatment

47: Acrocyanosis

Abstract

Epidemiology

Etiology

Pathophysiology

Clinical presentation

Diagnosis

Histopathology

Differential diagnosis
 Treatment

Prognosis

48: Erythromelalgia

Abstract

Definition and historical perspective

Nomenclature

Criteria for diagnosis

Clinical controversies

Clinical presentation

Diagnosis

Classification

Incidence

Pathophysiology

Differential diagnosis

Investigations

Natural History and Prognosis

Management

49: Pernio (Chilblains)

Abstract
 Epidemiology

Pathophysiology

Histopathology

Clinical features

Diagnosis

Treatment

Part XIV: Venous Thromboembolic Disease

50: Epidemiology of Venous Thromboembolic Disease

Abstract

Incidence and clinical relevance of venous thromboembolism

Secular trends in incidence of venous thromboembolism

Risk factors for venous thromboembolism

Classification of venous thromboembolism

Incidental venous thromboembolism

Conclusion

51: Clinical Evaluation of Venous Thromboembolism

Abstract

Clinical Presentation

Diagnosis
 Diagnosis in Pregnancy

Risk Stratification

Adjunctive Clinical Evaluation for Etiology of Venous

Thromboembolism

52: Management of Venous Thromboembolism

Abstract

Pathophysiology and Risk Factors for Venous

Thromboembolism

Anticoagulation

Recurrent Venous Thromboembolism and Optimal Duration of

Anticoagulation

Advanced Management of Venous Thromboembolism: When

Anticoagulation Alone May Not or Will Not Suffice

Strategies for Managing Acute Venous Thromboembolism

The Multitude of Challenges in Managing Venous Thrombosis

A Look Into the Future

Part XV: Chronic Venous Disorders

53: Varicose Veins

Abstract

Epidemiology

Anatomy
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 9. Tou] In 2 Samuel viii. 9 “Toi” (so Hebrew, but LXX. “Tou”).

Hamath] see above verse 3. Hamath is sometimes referred to as

the northern boundary of Israel, compare 1 Kings viii. 65; 2 Kings xiv.
25, 28.

¹⁰he sent Hadoram his son to king David, to

salute him, and to bless him, because he had
fought against Hadarezer and smitten him; for
Hadarezer had wars with Tou; and he had with
him all manner of vessels of gold and silver
and brass.
10. Hadoram] In 2 Samuel viii. 10, “Joram.” Both these forms are
probably Hebrew adaptations of the real name.

he had with him all manner of vessels] Such informal tribute was
an acknowledgment of David’s suzerainty made in order to claim
David’s protection in war. Compare the action of Asa (1 Kings xv. 18,
19) and of Ahaz (2 Kings xvi. 7, 8). In all three cases the policy was
the same, i.e. to acknowledge a distant suzerain and so gain the
benefit of a valuable alliance while losing the minimum of
independence.

¹¹These also did king David dedicate unto the

Lord, with the silver and the gold that he
carried away from all the nations; from Edom,
and from Moab, and from the children of
Ammon, and from the Philistines, and from
Amalek.
11. from Amalek] So 2 Samuel viii. 12, but we have no record of
any war of David with Amalek except the account in 1 Samuel xxx.
 ¹²Moreover Abishai ¹ the son of Zeruiah smote
of the Edomites in the Valley of Salt eighteen
thousand. ¹³And he put garrisons in Edom;
and all the Edomites became servants to
David. And the Lord gave victory ² to David
whithersoever he went.
¹ Hebrew Abshai. ² Or, saved David.

12. Abishai the son of Zeruiah] In 2 Samuel viii. 13 David, and in

Psalms lx. (title) Joab, receives the credit of this victory. Abishai
might have commanded in the battle, while Joab (compare 1 Kings
xi. 16) completed the conquest of the country; but it is highly
probable that the reading Abishai the son of Zeruiah has arisen here
through a copyist’s mistake and that the true reading is And when
he (David) returned he smote Edom, etc.

of the Edomites] Literally “of Edom,” so Psalms lx. (title), but in 2

Samuel “of the Syrians,” literally “Aram.” The two words “Edom” and
“Aram” when written in Hebrew are very much alike and are easily
confused. The reading “Edom” is right here.

the Valley of Salt] Probably the marshy flat (Bädeker, Palestine⁵,

p. 174) at the south end of the Dead Sea. This valley is dominated
by the Jebel Usdum, a hill consisting “almost entirely of pure
crystallised salt” (Bädeker, Palestine⁵, p. 174).

eighteen thousand] Psalms lx. (title), “twelve thousand,” not an

important variation.

14‒17 (= 2 Samuel viii. 15‒18; compare 2 Samuel xx. 23‒26).

David’s Officials.
 ¹⁴And David reigned over all Israel; and he
executed judgement and justice unto all his
people.
14. unto all his people] David was his own chief justice, but
probably the work was too much for one man; compare 2 Samuel xv.
2‒4.

¹⁵And Joab the son of Zeruiah was over the

host; and Jehoshaphat the son of Ahilud was
recorder ¹.
¹ Or, chronicler.

15. recorder] margin, chronicler; LXX., ὑπομνηματογράφος. His

business was probably to remind the king of his various duties of
state.

¹⁶And Zadok the son of Ahitub, and Abimelech

the son of Abiathar, were priests; and
Shavsha was scribe ¹;
¹ Or, secretary.

16. Abimelech the son of Abiathar] In 2 Samuel viii. 17,

Ahimelech the son of Abiathar, but read Abiathar son of Ahimelech
in both passages. Compare xv. 11, xxiv. 3, notes; and Kirkpatrick on
2 Samuel viii. 17.

Shavsha] 2 Samuel viii. 17, Seraiah; 2 Samuel xx. 25, Sheva;

and 1 Kings iv. 3 (perhaps), Shisha. Shisha and Shavsha probably
represent two different attempts to pronounce a foreign name,
perhaps Shamsha; Seraiah and Sheva are mere errors of
transcription. Foreigners were admitted to posts of authority in the
empire of David and Solomon; Ittai the Gittite and Uriah the Hittite
are instances.

scribe] margin, secretary. See 2 Kings xii. 10, xviii. 18, xxii. 3;
compare 2 Kings xxv. 19, a passage which suggests that there was
a second scribe with military duties. The first, the king’s scribe, would
formulate the king’s orders and conduct his correspondence with
foreign powers. Shavsha’s sons held the office in the reign of
Solomon, 1 Kings iv. 3.

¹⁷and Benaiah the son of Jehoiada was over

the Cherethites and the Pelethites; and the
sons of David were chief about the king.
17. Benaiah] Compare xi. 22‒25.

the Cherethites and the Pelethites] David’s bodyguard. The

Cherethites were almost certainly Philistines (1 Samuel xxx. 14;
Ezekiel xxv. 16; Zephaniah ii. 5), the Pelethites were probably also
Philistines (2 Samuel xv. 18). Foreign bodyguards are well-known in
history.

chief about the king] Literally, the chief at the kings hand, i.e.
formed the executive to carry out his commands; compare
Nehemiah xi. 24. In 2 Samuel viii. 18 (Revised Version) David’s sons
are described as priests, a statement which is in all probability
correct, but which the Chronicler, following the later theory of the
priesthood, could not accept (see Introduction, pp. xli. f.).

Chapter XIX.
1‒19 (= 2 Samuel x. 1‒19).
War with the Ammonites and their Aramean Allies.
 Chronicles here omits the story of David’s kindness in seeking
out and befriending Mephibosheth (Merib-baal) the son of Jonathan
(2 Samuel ix.), because he has ignored the story of David’s relations
with Saul. Further the Court History of David which occupies an
important place in 2 Samuel is passed over altogether in Chronicles
Consequently the shameful episode of Bath-sheba, and the rebellion
of Absalom vanish from the account of David. It is obvious how
greatly the presentation of David’s life and character is affected by
these omissions. Yet from his point of view the Chronicler is right in
passing these matters by in silence. He was concerned to present
David essentially as the founder of the religious life of Israel as a
kingdom and of the Temple as an institution of religion.

There are several variations in text between 2 Samuel x. and 1

Chronicles xix., e.g. verses 6, 7 (addition in Chronicles), 16
(omission from Chronicles), 18 (variation in reckoning).

¹And it came to pass after this, that Nahash

the king of the children of Ammon died, and
his son reigned in his stead.
1. after this] The war with Ammon has already been referred to
by anticipation in xviii. 11.

Nahash] Probably the Nahash mentioned in 1 Samuel xi. 1.

Ammon] The Ammonites were a kindred race to the Hebrews,

being descended according to tradition from Lot, the nephew of
Abraham; compare Deuteronomy ii. 19. The two Ammonite names
here given are pure Hebrew, Nahash (= “Serpent”) and Hanun (=
“Favoured, Fortunatus”); the Ammonite language, like the Moabite,
was doubtless very similar to Hebrew.

²And David said, I will shew kindness unto

Hanun the son of Nahash, because his father
shewed kindness to me. So David sent
 messengers to comfort him concerning his
father. And David’s servants came into the
land of the children of Ammon to Hanun, to
comfort him.
2. sent messengers to comfort him] A customary act of
international courtesy; compare 2 Kings xx. 12. Its breach was
resented. Thus in the Tell el-Amarna letters (x. 16) the king of
Kardunias writes, “Should not my brother (i.e. the king of Egypt)
have heard that I am sick? Why has he not comforted me? Why has
he not sent his messenger, not looked into it?” (editor H. Winckler, p.
23).

³But the princes of the children of Ammon said

to Hanun, Thinkest thou that David doth
honour thy father, that he hath sent comforters
unto thee? are not his servants come unto
thee for to search, and to overthrow, and to
spy out the land?
3. the land] 2 Samuel x. 3, the city, i.e. Rabbah (see xx. 1).

⁴So Hanun took David’s servants, and shaved

them, and cut off their garments in the middle,
even to their buttocks, and sent them away.
4. shaved them] 2 Samuel x. 4, shaved off the one half of their
beards. Of course a great insult; compare Isaiah l. 6.

cut off their garments] Jewish ambassadors are represented on

the Black Obelisk (a monument of Shalmaneser II, king of Assyria,
now preserved in the British Museum) as wearing robes reaching to
the feet; Hanun reduced ambassadors to the level of captives;
compare Isaiah xx. 4.

⁵Then there went certain, and told David how

the men were served. And he sent to meet
them; for the men were greatly ashamed. And
the king said, Tarry at Jericho until your
beards be grown, and then return.
5. Tarry at Jericho] Thus (1) the feelings of the ambassadors
would be spared, (2) the insult would be less widely known until it
had been avenged.

⁶And when the children of Ammon saw that

they had made themselves odious to David,
Hanun and the children of Ammon sent a
thousand talents of silver to hire them chariots
and horsemen out of Mesopotamia, and out of
Aram-maacah, and out of Zobah.
6. a thousand talents of silver] A very large sum; for a hundred
talents Amaziah hired a hundred thousand men (2 Chronicles xxv.
6).

chariots and horsemen] The Israelite armies on the contrary

consisted chiefly of infantry, the country being for the most part
unsuitable for horses.

Mesopotamia] Hebrew “Aram (Syria) of the two rivers” (compare

Genesis xxiv. 10, Revised Version margin), i.e. probably the land
between the Euphrates and the Chaboras. The Greeks used the
term Mesopotamia of a wider district, i.e. of the country between the
Euphrates and the Tigris. This mention of Mesopotamia is probably
premature, for in verse 16 the summons of Syrians from beyond the
Euphrates is spoken of as a new thing. The corresponding
expression in 2 Samuel x. 6 is Beth-rehob, a district which has not
yet been identified.

Aram-maacah] compare vii. 15, note; Deuteronomy iii. 14;

Joshua xii. 5, xiii. 11.

Zobah]. compare xviii. 3, note.

⁷So they hired them thirty and two thousand

chariots, and the king of Maacah and his
people; who came and pitched before
Medeba. And the children of Ammon gathered
themselves together from their cities, and
came to battle.
7. thirty and two thousand chariots] Compare 2 Samuel x. 6,
which reckons the army (including Maacah) at 33,000, of whom
20,000 are expressly described as footmen. The word “chariots” may
have slipped in from verse 6 instead of “men” or may be an
intentional alteration, magnifying the war.

Medeba] In the territory of Reuben; Joshua xiii. 26. The country

round is a table-land suited for the manœuvres of chariots. The
place of the rendezvous of the allies is not mentioned in 2 Samuel x.,
some words having probably fallen out of the text.

⁸And when David heard of it, he sent Joab,

and all the host of the mighty men. ⁹And the
children of Ammon came out, and put the
battle in array at the gate of the city: and the
kings that were come were by themselves in
the field.
 8. David ... sent Joab] Why in such a crisis did he not go himself?
Perhaps because he could watch the gathering of the more serious
storm described in verses 16‒19 better from Jerusalem.

¹⁰Now when Joab saw that the battle ¹ was set

against him before and behind, he chose of all
the choice men of Israel, and put ¹¹them in
array against the Syrians. And the rest of the
people he committed into the hand of Abishai ²
his brother, and they put themselves in array
against the children of Ammon. ¹²And he said,
If the Syrians be too strong for me, then thou
shalt help me: but if the children of Ammon be
too strong for thee, then I will help thee.
¹ Hebrew the face of the battle was against.

² Hebrew Abshai.

10. he chose of all the choice men] The Syrians were the more
formidable because of the chariots they had; Joab therefore opposed
to them the flower of his army.

¹³Be of good courage, and let us play the men

for our people, and for the cities of our God:
and the Lord do that which seemeth him
good.
13. the cities of our God] The cities which our God has given us
and in which He is worshipped. If these were captured by the enemy,
false gods would be worshipped in them. Religious feeling often
supplies the place of patriotism in the East.
 ¹⁴So Joab and the people that were with him
drew nigh before the Syrians unto the battle;
and they fled before him.
14. drew nigh before the Syrians] Without fear for their own rear
advanced against the Syrian front.

¹⁵And when the children of Ammon saw that

the Syrians were fled, they likewise fled before
Abishai his brother, and entered into the city.
Then Joab came to Jerusalem.
15. Joab came to Jerusalem] Probably because he was wanted
for the new danger gathering in the North.

16‒19.
The End of the Aramean War.

Three stages are apparent in the war with Zobah as related in

Chronicles, (a) that in which David secured a position on the
Euphrates, xviii. 3‒8, (b) the stage during which troops from Zobah
acted as auxiliaries to the Ammonites, xix. 6‒15, (c) the final stage
which ended in the conclusion of a formal peace, xix. 16‒19. The
actual facts of David’s activities against the Arameans are by no
means easy to ascertain, as may be seen in the commentaries on
the more complex account which is given in Samuel.

¹⁶And when the Syrians saw that they were

put to the worse before Israel, they sent
messengers, and drew forth the Syrians that
were beyond the River, with Shophach the
captain of the host of Hadarezer at their head.
 16. the Syrians that were beyond the River] i.e. the Syrians of
“Mesopotamia”; compare verse 6, note. 2 Samuel x. 16 adds, and
they came to Helam; the position of Helam however is unknown.

Shophach] In 2 Samuel x. 16 called “Shobach.” The whole allied

army was united under one general.

¹⁷And it was told David; and he gathered all

Israel together, and passed over Jordan, and
came upon them, and set the battle in array
against them. So when David had put the
battle in array against the Syrians, they fought
with him.
17. came upon them] or possibly read, as 2 Samuel x. 17, came
to Helam. According to 2 Samuel x. the Syrian army assembled at
Helam, and was there attacked by David.

¹⁸And the Syrians fled before Israel; and David

slew of the Syrians the men of seven
thousand chariots, and forty thousand
footmen, and killed Shophach the captain of
the host.
18. seven thousand] 2 Samuel x. 18, seven hundred: an
intentional change made by the Chronicler to enhance the
achievement of David.

forty thousand footmen] 2 Samuel x. 18, forty thousand

horsemen. Swarms of horsemen have usually formed the strength of
armies raised on the eastern bank of the Euphrates; but the reading
in Chronicles may well be correct.
 ¹⁹And when the servants of Hadarezer saw
that they were put to the worse before Israel,
they made peace with David, and served him:
neither would the Syrians help the children of
Ammon any more.
19. the servants] i.e. his vassals and tributaries; in 2 Samuel “all
the kings that were servants to Hadarezer.” We are not told what
course Hadarezer himself took; possibly, being deserted by his
allies, he ceased from hostilities without making any treaty with
David.

Chapter XX.
1‒3 (= 2 Samuel xi. 1, xii. 26‒31).
The Subjugation of Ammon.

The account of the siege of Rabbah is given more shortly in

Chronicles than in 2 Samuel From the latter we learn that the Ark
was in the besiegers’ camp (xi. 11), that the city was defended with
spirit (xi. 17), and finally taken piecemeal (xii. 26‒29).

¹And it came to pass, at the time of the

return of the year, at the time when kings go
out to battle, that Joab led forth the power of
the army, and wasted the country of the
children of Ammon, and came and besieged
Rabbah. But David tarried at Jerusalem. And
Joab smote Rabbah, and overthrew it.
 1. at the time of the return of the year] i.e. in the spring, 2 Samuel
xi. 1; 1 Kings xx. 22.

the power of the army] The Hebrew phrase is quite general in

meaning: the host of war, the military forces.

Rabbah] the capital of the Ammonites; Jeremiah xlix. 2; Ezekiel

xxi. 20 (25, Hebrew). Its site, now called ‘Ammān, is covered with
important ruins of the Roman and Byzantine periods. The town lies
in a fertile basin, its citadel on a hill on the north side.

David tarried at Jerusalem] In 2 Samuel these words introduce

the story of David’s adultery with Bath-sheba, which is omitted from
Chronicles.

Joab smote Rabbah] In 2 Samuel xii. 27 Joab reports to David

the capture of the city of waters (i.e. the lower city), and invites him
to come and complete the conquest (presumably by capturing the
citadel) in person. Probably the citadel was dependent for water on
the river which flows through the town.

²And David took the crown of their king ¹ from

off his head, and found it to weigh a talent of
gold, and there were precious stones in it; and
it was set upon David’s head: and he brought
forth the spoil of the city, exceeding much.
¹ Or, Malcam See Zephaniah i. 5.

2. of their king] So also Authorized Version, perhaps rightly, but

many scholars prefer to treat the word as a proper name, rendering,
as margin, of Malcam (compare Zephaniah i. 5), i.e. Milcom, the
national god of the Ammonites (1 Kings xi. 5). LXX. has a double
translation of the one Hebrew word: Molchol (Molchom) their king.
The name of the god, whether the right form be Molech (1 Kings xi.
7) or more probably Milcom or Malcam, means either “king” or, less
probably, “counsellor.” In the former case his image would in all
probability wear a crown.

it was set upon David’s head] A symbolic action implying that

David completely annexed the Ammonite territory; other conquered
nations retained a partial independence on condition of the payment
of tribute.

he brought forth the spoil of the city, exceeding much] doubtless

a triumphal procession of captives and spoil, such as an Assyrian
relief in the British Museum represents passing before Sennacherib
at the capture of Lachish.

³And he brought forth the people that were

therein, and cut them with saws, and with
harrows of iron, and with axes. And thus did
David unto all the cities of the children of
Ammon. And David and all the people
returned to Jerusalem.
3. and cut them with saws] Read probably (compare 2 Samuel
xii. 31, Revised Version margin) and put them with saws, i.e. put
them to work with saws, etc. Compare 2 Chronicles ii. 17, 18;
Joshua ix. 21‒23. The implements mentioned here and in the
parallel passage of 2 Samuel suggest task-work, not massacre. The
Ammonites were reduced to bondage like that of Israel in Egypt. The
exceptionally harsh treatment of the Ammonites was doubtless due
to the exceptional insults which David’s ambassadors had received
from them. A very different spirit towards Ammon is shown in
Deuteronomy ii. 19.

4‒8 (= 2 Samuel xxi. 18‒22).

Philistine champions slain.

This section is the last in which the Chronicler notices David’s

wars. It is taken from 2 Samuel xxi., where, however, it is preceded
by an account (verses 15‒17) of David’s narrow escape in an
encounter with a Philistine.

Between the two sections of this chapter the Chronicler omits the
account of the rebellions of Absalom and of Sheba, and the story of
the Gibeonite vengeance on the house of Saul (2 Samuel xiii. i‒xxi.
14).

⁴And it came to pass after this, that there

arose war at Gezer ¹ with the Philistines: then
Sibbecai the Hushathite slew Sippai, of the
sons of the giant ²: and they were subdued.
¹ In 2 Samuel xxi. 18, Gob.

² Hebrew Rapha. According to another reading, giants; Hebrew

Rephaim.

4. at Gezer] See vi. 67, note. In 2 Samuel at Gob, but no place

called Gob is known. In 2 Samuel v. 25 it is said that David smote
the Philistines “from Geba until thou come to Gezer.”

Sippai] In 2 Samuel “Saph.”

giant] Hebrew “Rapha”; the same Hebrew word in the plural

“Rephaim” is translated “giants” in Deuteronomy ii. 11, Authorized
Version These “Rephaim” dwelt east of Jordan.

⁵And there was again war with the Philistines;

and Elhanan the son of Jair slew Lahmi the
brother of Goliath the Gittite, the staff of
whose spear was like a weaver’s beam.
5. Elhanan ... slew Lahmi the brother of Goliath] In 2 Samuel xxi.
19, Elhanan ... the Beth-lehemite slew Goliath (Revised Version).
The difference between the two sentences in Hebrew is very small,
and is due, no doubt, to the Chronicler, or a copyist, who felt that he
was making a certain emendation in substituting the brother of
Goliath for Goliath himself, since, according to 1 Samuel xvii.,
Goliath was slain by David before he became king.

slew Lahmi] read the Beth-lehemite slew, etc.

⁶And there was again war at Gath, where was

a man of great stature, whose fingers and toes
were four and twenty, six on each hand, and
six on each foot; and he also was born unto
the giant ¹.
¹ Hebrew Rapha.

6. a man of great stature] In 2 Samuel xxi. 20 (Hebrew) a man of

contention, i.e. a challenger or champion.

⁷And when he defied ⁴ Israel, Jonathan the son

of Shimea David’s brother slew him.
⁴ Or, reproached.

7. Shimea] See iii. 5, note.

⁸These were born unto the giant ¹ in Gath; and

they fell by the hand of David, and by the hand
of his servants.
¹ Hebrew Rapha.
 8. These were born unto the giant in Gath] Again “giant” is the
Hebrew “Rapha” as in verses 4, 6. The meaning is that these
belonged to a branch of the Rephaim which was settled in Gath.
 Chapter XXI.
1‒27 (= 2 Samuel xxiv. 1‒25).
The Numbering and the Plague.

Comparison of these verses with the account given in Samuel

discloses not a few interesting divergences, the more important of
which are pointed out in the notes below (see especially the notes on
verses 1, 6, 25). In general it may be said that the account in
Chronicles curtails any features reflecting discredit on David and
expands such as do him honour. Some scholars consider that the
changes are of such a character that they may all be due directly to
the Chronicler, but others see in them motives so various as to
suggest the opinion that the Chronicler’s source is not Samuel but
an intermediate source. There may be a measure of truth in both
contentions. So famous a tale may well have been recounted with
modifications in the telling to suit the later idealisation of David. The
Chronicler may therefore have been working from the text of
Samuel, but some of the changes he introduced may have been
generally current, and for these he is in a sense not immediately
responsible, although of course all were more or less in accordance
with his taste.

The subject of the present section (David’s numbering of the

people and the plague which followed) is interesting in itself, quite
apart from the comparison with Samuel Why was the census
considered a sin? Various replies may be made. (1) Because the
pride of David and the ambitions which the census might promote
revealed a transference of trust from God to self, from spirit to
numbers, from justice to power. This view accords with our modern
moralistic standpoint, but other considerations call for mention.
(2) Because, unlike the two numberings in the wilderness (Numbers
i. 1‒16, iii. 39, xxvi. 1‒65), it was not made by Divine command
(compare verse 1, note). This thought may well have been present in
the mind of the Chronicler. To it we may add (3) the popular dread of
the census as a sinister and unlucky act. The ground of this dread
was no doubt mainly practical, being due to the fear that the records
might be used for purposes of fresh taxation or more stringent war-
levies, but it may have its roots in an instinct, handed down from the
thoughts of primitive ages, when written records were an uncanny
mystery. Thus S. I. Curtiss, Primitive Semitic Religion To-day, p. 69,
remarks that the persistence of this fear among modern Semites is
partially chargeable for the lack of correct statistics as to the
population of Oriental towns. Frazer (in Anthropological Essays to
E. B. Tylor, p. 174) refers to the dread of enumeration felt by the
Lapps and by a West African tribe.

¹And Satan ¹ stood up against Israel, and

moved David to number Israel.
¹ Or, an adversary.

1. And Satan stood up against Israel] In 2 Samuel “And again (a

former occasion being at the time of the famine, 2 Samuel xxi. 1) the
anger of the Lord was kindled against Israel, and he moved David
against them.” The change is significant of the late date of
Chronicles In an earlier stage of Hebrew thought human sin and folly
are at times naïvely ascribed to the agency of God, e.g. “He hardens
Pharaoh’s heart” (Exodus x. 1, etc.): “quem Deus vult perdere prius
dementat.” At a later date the instigation of some subordinate “evil”
spirit was adduced, e.g. 1 Kings xxii. 20‒24; and eventually this spirit
of temptation was expressly termed “The Satan” or “Satan,” i.e. “The
Adversary.” He was then regarded as a hostile spiritual being, the
opposite of a guardian angel such as the Michael of Daniel x. 13, 21,
xii. 1. In the book of Job the Satan is very definitely said to act under
the guidance and will of God. Here nothing is said of the Satan
having been directed by Jehovah.
 to number] Only those of military age (verse 5), over twenty years
of age (xxvii. 23, 24), were included in the census.

²And David said to Joab and to the princes of

the people, Go, number Israel from Beer-
sheba even to Dan; and bring me word, that I
may know the sum of them.
2. to Joab] The object being to number “those who drew sword,”
the captain of the host was the most suitable person to entrust with
the business.

from Beer-sheba even to Dan] From the extreme south to the

extreme north of the land.

Dan] The modern Tell el-Kādī, about forty minutes distance from
Bāniās (Paneas), north of Lake Huleh (Waters of Merom). For its
original name Laish, see Judges xviii. 28.

that I may know] Either with a view to imposing a tax or to

undertaking some fresh great military expedition.

³And Joab said, The Lord make his people an

hundred times so many more as they be: but,
my lord the king, are they not all my lord’s
servants? why doth my lord require this thing?
why will he be a cause of guilt unto Israel?
3. The Lord make ... are they not all my lord’s servants?]
Counting will not increase their numbers, only Jehovah’s gracious
favour can secure that. What more then can David desire than to
know, as Joab now assures him, that one and all his subjects are
loyal?