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No More Joint Pain
 Yale University Press Health & Wellness

A Yale University Press Health & Wellness book is an authoritative,

accessible source of information on a health-related topic. It may provide
guidance to help you lead a healthy life, examine your treatment
options for a specific condition or disease, situate a healthcare issue in
the context of your life as a whole, or address questions or concerns
that linger after visits to your healthcare provider.

Joseph A. Abboud, M.D., and Soo Kim Abboud, M.D., No More Joint
Pain

Thomas E. Brown, Ph.D., Attention Deficit Disorder: The Unfocused

Mind in Children and Adults

Marjorie Greenfield, M.D., The Working Woman’s Pregnancy Book

Ruth H. Grobstein, M.D., Ph.D., The Breast Cancer Book: What You
Need to Know to Make Informed Decisions

James W. Hicks, M.D., Fifty Signs of Mental Illness: A Guide to

Understanding Mental Health

Steven L. Maskin, M.D., Reversing Dry Eye Syndrome: Practical Ways

to Improve Your Comfort, Vision, and Appearance

Mary Jane Minkin, M.D., and Carol V. Wright, Ph.D., A Woman’s Guide
to Menopause and Perimenopause

Mary Jane Minkin, M.D., and Carol V. Wright, Ph.D., A Woman’s Guide
to Sexual Health

Arthur W. Perry, M.D., F.A.C.S., Straight Talk About Cosmetic Surgery

Catherine M. Poole, with DuPont Guerry IV, M.D., Melanoma: Preven-

tion, Detection, and Treatment, 2nd ed.

E. Fuller Torrey, M.D., Surviving Prostate Cancer: What You Need to

Know to Make Informed Decisions

Barry L. Zaret, M.D., and Genell J. Subak-Sharpe, M.S., Heart Care for
Life: Developing the Program That Works Best for You
 No
More
Joint Pain

Joseph A. Abboud, M.D.,

and Soo Kim Abboud, M.D.

Yale University Press New Haven and London

The information and suggestions contained in this book are not intended to replace the services of
your physician or caregiver. Because each person and each medical situation is unique, you should
consult your own physician to get answers to your personal questions, to evaluate any symptoms you
may have, or to receive suggestions for appropriate medications.
The authors have attempted to make this book as accurate and up to date as possible, but
it may nevertheless contain errors, omissions, or material that is out of date at the time you read it.
Neither the authors nor the publisher has any legal responsibility or liability for errors, omissions,
out-of-date material, or the reader’s application of the medical information or advice contained in
this book.

Published with assistance from the foundation established in memory of Philip Hamilton McMillan
of the Class of 1894, Yale College.

Copyright © 2008 by Joseph Abboud, M.D.

All rights reserved.
This book may not be reproduced, in whole or in part, including illustrations, in any form (beyond
that copying permitted by Sections 107 and 108 of the U.S. Copyright Law and except by reviewers
for the public press), without written permission from the publishers.
Designed by Gregg Chase
Set in by Ehrhardt by Tseng Information Systems, Inc.
Printed in the United States of America.
Library of Congress Cataloging-in-Publication Data
Abboud, Joseph A.
No more joint pain / Joseph A. Abboud and Soo Kim Abboud.
p. cm.—(Yale University Press health & wellness)
Includes bibliographical references and index.
isbn 978-0-300-11175-0 (hardcover : alk. paper)
1. Joints—Diseases—Popular works. 2. Pain—Popular works. 3. Arthritis—Popular works.
I. Abboud, Soo Kim. II. Title.
rc932.a23 2008
616.7'2—dc22
2007039386
A catalogue record for this book is available from the British Library.
The paper in this book meets the guidelines for permanence and durability of the Committee on
Production Guidelines for Book Longevity of the Council on Library Resources.
10 9 8 7 6 5 4 3 2 1
 This book is dedicated to the memory of my father,
Albert Abboud, who taught me the importance of education,
perseverance, and intellectual curiosity
This page intentionally left blank
 Contents

I n t r o d u c t i o n
The Many Causes of Joint Pain 1

Pa r t O n e
Where Joint Pain Occurs 25

1 The Back 27
2 The Hip 56
3 The Knee 83
4 The Foot and Ankle 111
5 The Shoulder 134
6 The Elbow 153
7 The Hand and Wrist 169

Pa r t T w o
Treating Joint Pain 189

8 Common Medications and How They Work 191

9 When to Consider a Joint Injection 208
10 Alternative Therapies 214

Ep i l o g u e
Possible Future Therapies 223

Acknowledgments 233
Appendix: Resources for Additional Information 235
Glossary of Frequently Used Terms 239
References 243
Index 267
This page intentionally left blank
No More Joint Pain
This page intentionally left blank
 Introduction

The Many Causes of Joint Pain

there are about a hundred different forms of arthritis, an umbrella

term for diseases with symptoms that include joint and musculoskeletal
pain. And if you live long enough, you can pretty much count on develop-
ing symptoms of one of them—a touch of osteoarthritis, at the very least.
In fact, more than 50 percent of people over age sixty-five have clinical
signs of arthritis, meaning that an estimated seventy million Americans
suffer from the disease. As the life expectancies for men and women con-
tinue to increase, Americans over the age of sixty-five will continue to
be the most rapidly growing segment of the population. Consequently,
according to even the most conservative estimates, the number of patients
suffering from arthritis will nearly double by the year 2030 (a statistic that
includes not only forms that emerge in the later years, but also those varia-
tions that affect young children, or adults in their prime). And osteoar-
thritis, the most prevalent form of arthritis, is the most common chronic
disease affecting older individuals today.
Given this growing prevalence of osteoarthritis, it is not surprising
that the health-care industry, which encompasses both traditional and un-
conventional modes of research and treatment, is rushing to develop and
propose miracle cures—and that seniors who are confronted with arthritis
can be all too ready to try them. After all, although Americans today look
forward to living into and past their seventies and eighties, none imagine


 introduction

Almost everybody
experiences joint pain
at some point in their
lifetime.

Image not available

their golden years crippled with arthritis or envision their independence

and quality of life hampered by other causes of joint pain. Our hope is
that this book will help you become an educated health-care consumer—
one who can easily distinguish among effective mainstream treatments,
reasonable alternative treatments, and outright scams. In addition, while
medical and surgical advances have given new hope to millions of joint
pain and arthritis sufferers, this book will also stress the importance of
arthritis prevention for readers who understand that early steps to avoid
disease are always the best cure.

Anatomy of a Joint
Human beings have more than one hundred joints connecting over two
hundred bones, most of which are specifically designed to allow a broad
range of motion. There are many different kinds of joints: ball-and-socket
joints (think hips and shoulders), saddle joints (which connect thumb to
hand), hinge joints (like those in your fingers and knees), or pivot joints
(your wrists, for example).
In its simplest form, a joint is a connection between two or more
bones and is made up of the ends of the bones; tough, rubbery cartilage
that wraps around the ends of the two bones and that also functions as a
shock absorber; a fluid-filled capsule that surrounds the bone ends and
cartilage; and various ligaments and tendons that provide both stability
 i n t r o d u c t i o n​ 

Arthritis Facts

• According to the Centers for Disease Control and

Prevention, one in three adults in the United States suffers
from arthritis or chronic joint pain.
• Almost twice as many women as men suffer from arthritis.
• Arthritis accounts for nearly forty million doctor visits and
more than half a million hospitalizations.
• Osteoarthritis is the most common form of arthritis, afflicting
more than twenty million Americans.
• Rheumatoid arthritis and gout are the second and third
most common causes of arthritis. While rheumatoid arthritis
strikes mostly women, gout tends to afflict men.
• Gout is twice as likely to strike African-American men
as Caucasian men. This may be because more African-
American men suffer from hypertension and take medication
to lower their blood pressure. Some of these antihypertensive
drugs can increase production of uric acid—the substance
that crystallizes and then deposits in gouty joints.
• An astonishing 285,000 children under age seventeen have
arthritis, including 50,000 who have juvenile rheumatoid
arthritis.

and movement. Inside the joint capsule a special lining—the synovial

membrane, or synovium—makes a slick liquid called the synovial fluid
that lubricates the joint. In many forms of arthritis, the synovium becomes
inflamed and thickened, producing extra fluid containing inflammatory
cells. Under the right circumstances, these inflammatory cells can then
attack and damage the cartilage and the bone underlying it.
Although scientists researching arthritis have come a long way
toward understanding how joints work, we still don’t know exactly what
causes arthritis. Even so, prevention, early detection, and appropriate
medical and surgical treatment can help most arthritis sufferers.
 Bone is a living and
dynamic organ.

Image not available

Anatomy
of a normal
joint.

Image not available

 i n t r o d u c t i o n​ 

Different
types of
joints in
your body.

Image not available

A joint with
osteoarthritis.

Common Forms of Arthritis: An Overview

Osteoarthritis, the most common form of arthritis, occurs when joint car-
tilage breaks down, exposing bone ends and allowing them to rub together.
The result can be pain, stiffness, loss of movement, and, sometimes, swell-
ing. Osteoarthritis is most often found in the weight-bearing joints such as
the hips, knees, ankles, and spine. There are many causes of osteoarthritis,
including trauma, obesity, genetics, and other factors.
Rheumatoid arthritis is the second-most-common form of arthri-
 introduction

Image not available

tis, and it occurs when the immune system turns against the body. The
faulty immune system causes inflammation and swelling that begins in the
joint lining and spreads to the cartilage and the bone. Rheumatoid arthri-
tis tends to affect joints symmetrically—in other words, it tends to affect
the same joint on both sides of the body (for example, both hands or both
wrists).
Gout is caused by the buildup of uric acid, which forms crystals
that deposit in the joint. These needlelike crystals cause inflammation
 i n t r o d u c t i o n​ 

Ankylosing spondylitis leads to

loss of normal spine curvature.

Image not available

leading to severe pain and are most commonly found in the knees, the
wrists, and the big toe. Heredity, diet, and certain drugs may cause or ex-
acerbate gout.
Pseudogout occurs when calcium crystals deposit within joints.
The symptoms are similar to those of gout, but, unlike gout, pseudogout
is not caused or exacerbated by dietary habits.
Ankylosing spondylitis is a chronic inflammation of the spine that
causes the vertebrae to eventually fuse together, giving the spine a very
rigid appearance. Although the cause is unknown, genetics is thought to
play a large role.
Infectious arthritis occurs when bacteria, viruses, or fungi enter
the body, settle in the joints, and cause fever, inflammation, and joint de-
struction.
Juvenile arthritis encompasses different kinds of arthritis that
strike children under the age of sixteen, the most common of which is
juvenile rheumatoid arthritis. Pain or swelling in the shoulders, elbows,
knees, ankles, or toes; chills; a reappearing fever; and sometimes a body
rash are many of the common symptoms. The cause remains unknown.
Psoriatic arthritis occurs in conjunction with the inherited skin
condition psoriasis, which causes scaly, red, rough patches on the neck,
elbows, and knees. Psoriatic arthritis often afflicts the joints of the fingers
and toes, causing the digits to swell.
 introduction

Typical appearance of a
hand afflicted with psoriatic
arthritis.

Image not available

The Many Causes of Joint Pain

Whether arthritis has developed because of genetic factors or, far more
commonly, torn cartilage, sprains, and dislocations, joint pain is a condi-
tion that can be most effectively treated—and prevented—when its causes
are understood.

Osteoarthritis
As mentioned earlier, osteoarthritis, which is sometimes called degenera-
tive arthritis or degenerative joint disease, is the result of the breakdown
of cartilage inside the joint. When the cartilage that cushions bone ends no
longer does its job, the bone ends can’t slide easily across each other within
the joint. That’s when the pain and stiffness begin.

What Is Cartilage?
Three different types of cartilage are found in the body. The smooth ar-
ticular, or hyaline, cartilage covers joint surfaces. Its function is to provide
a low-friction surface to help the joint withstand the stress and strain that
occurs with daily weight-bearing activities such as walking, stair climb-
ing, and exercise. The ultrastrong fibrocartilage is found in the knee and
 i n t r o d u c t i o n​ 

Image not available

Our joints are complex structures that on a microscopic level involve the
intricate interaction of cells (chondrocytes), water, collagen, and various
proteins such as proteoglycans.

within the vertebral disks and is used to help connect bones. And the stiff
but soft elastic cartilage, which is used to keep open passageways in the
body, is found in such places as the ear canals and the throat.
Cartilage is made up of four ingredients:
1. Water. Most of cartilage, 65–85 percent, is water, which lubricates
the joints, cushions bones, and absorbs shock.
2. Collagen. The joint gains elasticity and the ability to be a shock
absorber from collagen, a connective tissue that is arranged in a
meshlike framework and holds bones and muscles together.
3. Proteoglycans. The large molecules called proteoglycans embed
themselves securely into the collagen mesh and soak up water like
a sponge (they can also release water). The proteoglycans allow
cartilage to expand and contract, molding to the shape of the joint
as the pressure within the joint capsule changes with activity.
4. Chondrocytes. The important chondrocyte cells break down and
get rid of old proteoglycan and collagen molecules, forming new
ones to take their place.
10 introduction

How Osteoarthritis Starts

Osteoarthritis occurs when the articular cartilage within the joint becomes
disrupted (from a variety of reasons). These articular cartilage injuries can
occur as a result of a sudden injury (such as a car accident or sports injury)
or from ordinary wear and tear. Depending on the extent of the damage
and the location of the injury, articular cartilage can sometimes heal itself,
but complete restoration is difficult because articular cartilage has no di-
rect blood supply. (Perhaps surprisingly, an injury that involves the bone
beneath the cartilage has a better chance of healing despite being a deeper
injury, because the underlying bone will provide some blood for the carti-
lage to renourish and possibly heal itself.)
Osteoarthritis generally develops in three stages. First, there is a
loss of cartilage or an injury to the cartilage within the affected joint. Sec-
ond, the body tries to repair the cartilage and is unsuccessful; and third,
the bone beneath the cartilage becomes sclerotic, meaning that it becomes
abnormally thickened or hardened.
Once your cartilage is damaged, the tissue that is laid down to try
to repair the injury is always biomechanically inferior to articular carti-
lage. In addition, injured cartilage will occasionally lay down bone instead
of cartilage in its attempt to heal itself, forming an irregular surface that
doesn’t glide smoothly against the cartilage on the opposing bone end.
Sometimes, too, the cartilage doesn’t try to repair itself at all. Pieces of
loose cartilage and/or bone may break off and float freely around the joint
(these are called loose bodies, or joint mice, and can sometimes cause the
joint to lock). Now the bone ends are no longer well padded, and they
start to rub against each other and begin to develop bony spurs (osteo-
phytes). The joint space narrows, and the entire shape of the joint begins
to change. All this from a little damaged cartilage.

Signs and Symptoms of Osteoarthritis

How do you know whether the joint pain you’re suffering from is the re-
sult of osteoarthritis? Most of those with the disease have at least one of
the following symptoms:

Joint pain. Most people experience joint pain as a deep-seated

ache. The feeling is different from a muscular ache and may come
and go according to changes in the weather. People sometimes say,
“I can feel it in my bones when it’s going to rain.” The pain is
 i n t r o d u c t i o n​ 11

usually worse with activity and better with rest, although the pain
can become more constant in later stages.
Stiffness. Stiff joints, limited range of motion, and, in later stages,
joints that don’t move at all are all signs of osteoarthritis. Morning
stiffness is present but usually lasts less than thirty minutes.
Swelling. Although swelling does not always occur with osteo-
arthritis, some joints do swell in response to the cartilage damage
found in osteoarthritis. The finger joints and the knees are most
often affected.
Bony growths on the fingers. Bony lumps, either at the ends
of the fingers (called Heberden’s nodes) or on the middle joint of
the fingers (called Bouchard’s nodes), are signs of osteoarthritis.
These types of bony growths may be hereditary.

Causes of Osteoarthritis
When we don’t know why cartilage deteriorates, we designate the problem
as primary osteoarthritis, or osteoarthritis of unknown cause. Approxi-
mately 80–90 percent of individuals older than sixty-five suffer from pri-
mary osteoarthritis. Osteoarthritis of known cause, by contrast, is called
secondary arthritis. This kind of arthritis typically afflicts younger indi-
viduals, and it can occur after an injury, infection, or other trauma to the
cartilage.
The cause of primary osteoarthritis remains unknown. Although
scientists aren’t sure why, the collagen mesh of the cartilage becomes
scrambled; it weakens and can’t hold its structure. The proteoglycans
lose their place in the collagen mesh, and, as they float off into the joint
fluid, they take their water-retaining abilities with them. The cartilage
is left high and dry; it thins and may even crack. At the same time, the
newly freed proteoglycans draw excess fluid into the joint capsule, causing
­swelling.
Some ideas about what causes primary arthritis are emerging
among experts:
• The chondrocytes that are responsible for creating enzymes that
break down and replace the collagen and proteoglycan mole-
cules may become inefficient. In healthy cartilage, the amount of
breaking-down enzymes is equal to the amount of building-up
12 introduction

enzymes. An overabundance of destructive enzymes would lead to

weakened collagen and a lack of proteoglycans.

• In an almost opposite scenario, the chondrocytes may go wild

and start making too many proteoglycan and collagen molecules.
Ironically, the excess proteoglycan and collagen molecules that
are made end up pulling extra fluid into the joint, flooding it and
washing away most of the chondrocytes. The cartilage, then, is
left without any cartilage-producing molecules.

• Conditions that lead to cartilage loss and potentially secondary

osteoarthritis include injury, obesity, crystal deposits, infection,
congenital abnormalities (abnormalities present at birth), or joint
surgery. In particular:

Joint injury. Once a joint has been injured, it is more likely to

develop arthritis. If you have suffered a traumatic injury from an
event such as a motor vehicle accident, have played rough-and-
tumble sports, or have injured any of your joints in any way, you are
more likely to develop osteoarthritis in the joints that were affected
by those activities.

Repetitive motion injury (overuse). Joints that are repeatedly

stressed in the same way are more likely to experience cartilage
breakdown than joints subjected to normal use. Ballet dancers, as-
sembly line workers, baseball pitchers, carpenters, heavy laborers,
and anyone else who overuses and stresses a joint or joints can suf-
fer from cartilage breakdown in their overused joints.

Damage to the end of the bone. Usually the result of trauma

or continual stress, a bone may chip or sustain small fractures. The
body, in its attempt to repair the damage, may cause an overgrowth
of bone in the injured area. The result is a bone end that is bumpy
rather than smooth.
Bone disease. A bone disorder such as Paget’s disease may weaken
the bone structure, making it more likely to fracture and develop
bony overgrowth.

Carrying too much body weight. The heavier you are, the
more stress your knees, hips, and ankles must bear. Osteoarthri-
tis of the knee has been linked to excess body weight. That’s not
 i n t r o d u c t i o n​ 13

surprising considering that every time you take a walking step the
stress on your knee is roughly equivalent to three times your body
weight, and, when you run, that figure is increased to about ten
times your body weight.

Contributing Risk Factors for Osteoarthritis

Although osteoarthritis affects millions of Americans, not everyone suf-
fers from it. Some people grow old with joints unaffected by pain, stiff-
ness, or other symptoms, whereas others are hobbling around by the time
they are thirty-five. Why does one person get osteoarthritis while another
stays healthy? And how can you tell if you are susceptible to developing
the disease?
In addition to the risk factors detailed earlier for secondary osteo-
arthritis, your chances of developing the disease vary according to:
Your race. The disorder is more prevalent in Native Americans
than in the general population. Disease of the hip is seen less fre-
quently in native Chinese than in Caucasians of similar age. In per-
sons older than sixty-five years of age, osteoarthritis is more com-
mon in whites than in blacks.
Your age. Cartilage and other joint structures, like most bodily
tissues, tend to degrade and become weaker over time. After de-
cades of use, they start to wear out. Luckily, research has shown
that osteoarthritis isn’t inevitable as we age—just more likely.
Your sex. In individuals older than fifty-five, the prevalence of
osteoarthritis is higher among women than among men. In those
younger than forty-five, however, the prevalence of osteoarthritis
is higher among men. Women are especially susceptible to osteo-
arthritis in the distal interphalangeal joints (the finger joint closest
to the fingernail). Osteoarthritis of the hip, by contrast, appears to
occur more commonly in men than in women.
Your parents. There appears to be a genetic component to osteo-
arthritis; in fact, one study concluded that genes were responsible
for 50 percent of hip osteoarthritis cases. Osteoarthritis in the hands
is also believed to be at least partially due to genetics. An inherited
tendency toward defective cartilage or poorly structures joints can
certainly put you on the road to osteoarthritis, although you won’t
necessarily develop it.
14 introduction

Typical findings associated with

osteoarthritis of the hand.

Image not available

Diagnosing Osteoarthritis
Osteoarthritis is diagnosed mainly by detailed history and physical exami-
nation, because many common laboratory tests are not helpful in diagnos-
ing the disease. For example, although osteoarthritis is quite common in
people over age sixty-five, fewer than half of those who suffer from it—
and generally only those with advanced cases of the disease—have symp-
toms visible via conventional X-rays. Magnetic resonance imaging is more
sensitive, but in some cases direct visualization of the joint during surgery
(arthroscopy) is the only way to know for sure whether osteoarthritis is the
correct diagnosis.
To further aid in the diagnosis of osteoarthritis in particular joints,
the American College of Rheumatology has come up with two sets of cri-
teria for such a diagnosis:
For the knee: The patient has knee pain and osteophytes, and is
either (1) over age fifty, (2) suffering from stiffness of the knee joint
for more than thirty minutes a day, or (3) experiencing crepitus
(crunchiness in the joint).
For the hip: The patient is having hip pain and has two of the
following diagnostic features: X-ray evidence of osteophytes, X-
ray evidence of joint narrowing, and an erythrocyte sedimentation
rate (ESR) of less than twenty. ESR levels are typically high in
patients suffering from autoimmune disease or infection, and these
 i n t r o d u c t i o n​ 15

The mechanism of
joint destruction and
associated symptoms
of rheumatoid
arthritis.

Image not available

processes need to be ruled out prior to diagnosing a patient with

osteoarthritis.

Rheumatoid Arthritis
Rheumatoid arthritis is a case of the human body’s good intentions gone
awry. Your body is equipped with a very effective immune system that
fights off bacteria and other foreign bodies. Specialized immune cells at-
tack these invaders, surround them, paralyze them, and destroy them. A
strong, intact immune system is absolutely essential to your survival—
without it, you would quickly be overcome by infections and disease. But
with rheumatoid arthritis, your immune system goes haywire and starts
attacking your body’s own tissues. That is, when you have rheumatoid ar-
thritis, your own immune system (T cells) attacks the tissues that cushion
and line your joints, eventually causing entire joints to deteriorate. Rheu-
matoid arthritis can affect any joint in the body. But it usually affects the
small joints in the hands and feet before any of the larger joints, such as
hips or knees.
Although the condition can develop at any age, rheumatoid arthri-
tis is most likely to emerge between the ages of twenty and forty-five. It
seems that the older you are when rheumatoid arthritis first strikes, the
milder your case is likely to be. Rarely, children under the age of sixteen
can develop a form of rheumatoid arthritis known as juvenile rheumatoid
16 introduction

Notable Individuals with Rheumatoid Arthritis

• Actress Lucille Ball, whose left leg became shorter than her
right as a result of the disease.
• Impressionist painter Pierre-Auguste Renoir, who struggled
with painful rheumatoid arthritis but still completed
artworks infused with joy. He is thought to have once said
about his art, “The pain passes but the joy remains.”
• The Roman emperor Diocletian, who exempted citizens
with severe arthritis from paying taxes, no doubt realizing
that the disease itself can be taxing enough.

arthritis, or Still’s disease. Rheumatoid arthritis afflicts all ethnic groups,

yet despite some very serious consequences many people with rheumatoid
arthritis live long, successful lives. Just remember that early treatment can
make a big difference, so don’t wait to see a doctor.

The Body Becomes Its Own Worst Enemy

For reasons that aren’t completely understood, in rheumatoid arthritis the
white blood cells of the immune system attack the joint lining (synovial
membrane) as if it were a foreign object. Pain, loss of movement, and joint
destruction are the unhappy results. After the immune system goes to
work on the joint lining,
1. The assaulted membrane becomes inflamed and painful, the en-
tire joint capsule swells, and the synovial cells start to grow and
divide in an abnormal way.
2. The now abnormal synovial cells start to invade the surrounding
tissue—mostly the bone and cartilage.
3. The joint space begins to narrow, and the joint’s supporting
structures become weak. At the same time, the cells that trigger
inflammation release enzymes that eat away at the bone and carti-
lage, causing joint erosion and scarring.
4. The joint itself deteriorates, eventually becoming deformed.
 i n t r o d u c t i o n​ 17

Symptoms of Rheumatoid Arthritis

Although the symptoms of rheumatoid arthritis vary, most people experi-
ence one or more of the following:
• Pain, warmth, redness, swelling, or tightness in a joint
• Swelling of three or more joints for six or more weeks
• Joints affected in a symmetrical pattern (for example, both knees)
• Joint pain or stiffness lasting longer than an hour upon arising in
the morning or after prolonged inactivity
• Pea-shaped bumps under the skin (called rheumatoid nodules),
especially on pressure points like the elbows or the feet. In bed-
ridden patients, they may also occur at the base of the scalp or on
the back hip area
• Evidence of joint erosion on an X-ray
• Loss of mobility
• General soreness, aching, or stiffness
• A general “sick” feeling (malaise)
• Fatigue and weakness
• Periodic low-grade fever and/or sweating
• Difficulty sleeping
• Anemia (low blood count)
Rarely, rheumatoid arthritis causes problems with other parts of the body.
These problems may include inflammation of the blood vessels (vascu-
litis), inflammation of the linings of the lung or the heart, and dryness of
the eyes and mouth (Sjogren’s syndrome).

Possible Causes of Rheumatoid Arthritis

The truth is that nobody really knows what causes rheumatoid arthritis,
although some believe it is linked to a defect in the immune system. Many
people with the disease have a particular genetic marker—HLA-DR4—
although not everyone with this gene ends up with rheumatoid arthritis
(and not everyone with rheumatoid arthritis has this gene). Most scientists
18 introduction

currently believe that HLA-DR4 is only one of several genes that predis-
pose someone to developing the disease.
Some researchers believe that rheumatoid arthritis may be trig-
gered by a virus or bacteria that causes the immune system to wrongly
attack the lining of the joints (perhaps because the virus houses molecules
that, to the immune system, look similar to molecules within the joint).
Unfortunately, this infectious agent has yet to be found. Other researchers
believe that hormones may be involved in the development of rheumatoid
arthritis. Women are more likely than men to develop rheumatoid arthri-
tis, suggesting a possible link to estrogen.

Diagnosing Rheumatoid Arthritis

There is no single test that can diagnose rheumatoid arthritis. Instead, the
diagnosis is typically made by a physician based on:
• A full medical history, including any family history of rheumatoid
arthritis
• Discussion of current symptoms
• A physical examination of the joints and skin, as well as tests of
reflexes and muscle strength
• X rays
• Blood tests. Two blood tests commonly performed to assist in
the diagnosis of rheumatoid arthritis are a screen for rheumatoid
factor (or RhF), a protein produced by the immune system that
is present in as many as 80 percent of people with rheumatoid
arthritis, and an erythrocyte sedimentation rate (an elevated ESR
usually indicates the presence of inflammation somewhere in the
body).

Other Common Causes of Joint Pain

Many people who are active in sports find themselves injured from time
to time. Unfortunately, such injuries can reemerge decades later as pain
in the parts of the joint called ligaments and tendons. While both add to
our joint stability, each has a very specific role within the joint: ligaments
attach bone to bone, whereas tendons attach muscle to bone. The most
common types of joint injuries are ligament sprains, bone bruises or con-
tusions, cartilage tears, bony dislocations, and fractures (broken bones).
 i n t r o d u c t i o n​ 19

Here we describe these injuries only briefly; later chapters will focus in
depth on specific injuries to each joint.

Sprains
A sprain is an injury to a ligament. In a sprain, one or more ligaments is
stretched or torn. Falling, twisting, or getting hit can force a joint out of
its normal position, causing ligaments around the joint to stretch or tear.
Sprains happen most often in the ankle.
The usual signs and symptoms of a sprain are pain, swelling, bruis-
ing, and not being able to move or use a joint. Sometimes people feel a
pop or tear when the injury happens. A sprain can be mild, moderate, or
severe. Most sprains can be treated effectively with rest, ice, compression,
and elevation (RICE), although as we explain in later chapters, certain
severe, recurrent tears may require a trip to the operating room for re-
pair.

Strains
A strain occurs when a muscle or a tendon is stretched or torn after being
twisted or pulled. Strains can happen suddenly or develop over a period
of time. Acute strains are usually caused by lifting objects the wrong way
or by overstressing muscles; chronic strains are usually caused by moving
the muscles and tendons the same way over and over. Muscles that are
most commonly strained are the back muscles and the hamstring muscles
in the back of the thigh. A strain can cause pain, muscle spasms, muscle
weakness, swelling, cramping, and difficulty in moving the muscle.

Torn Cartilage
Torn cartilage is frequently seen around or in the knee in sports that cre-
ate sudden twisting motions such as football, basketball, or tennis. Treat-
ment usually involves physical therapy if the injury is minor or, if the
injury is more severe, surgery to remove the torn cartilage pieces. This
intervention is important because mature cartilage generally does not heal
itself well; consequently, torn cartilage can and often does lead to osteo-
arthritis.

Dislocations
Dislocations occur when injuries push the bones out of their normal posi-
tions within the joint. Treatment of bony dislocations involves the realign-
ment of the bones by a medical professional. These types of injuries can
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RAPHAEL SANZIO 903 1508 (Louvre); the " Eszterhazy

Madonna," probably the same year; as well as the " Madonna del
Cardellino " (Uffizi), the " Tempi Madonna " (Munich), the " Colonna
Madonna " (Berlin), the " Bridgewater Madonna " (Bridgewater
House), and the " Orleans Madonna " (due d'Aumale's collection).
The " Ansidei Madonna " was bought in 1884 for the National Gallery
from the duke of Marlborough for £70,000, .more than three times
the highest price ever before given for a picture.1 It was painted for
the Ansidei family of Perugia as an altarpiece in the church of S.
Fiorenzo, and is a work of the highest beauty in colour, well
preserved and very large in scale. The Virgin with veiled head is
seated on a throne, supporting the Infant with one hand and holding
a book in the other. Below stands S. Niccolo da Tolentino, for whose
altar it was painted; he holds a book and a crozier, and is clad in
jewelled mitre and green cope, under which appear the alb and
cassock. On the other side is the Baptist, in red mantle and camel's-
hair tunic, holding a crystal cross. The rich jewellery in this picture is
painted with Flemish-like minuteness. On the border of the Virgin's
robe is a date, formerly read as MDV by Passavant and others; it
really is MDVI or MDVII. If the later date is the true one, the picture
was probably begun a year or two before. A. favourite method of
grouping his Holy Families is that seen in-the " Madonna del
Cardellino " and the " Bella Giardiniera," in which the main lines form
a pyramid. This arrangement is also used in the " Madonna del
Giardino " and in the larger group, including St Joseph and St
Elizabeth, known as the " Canigiani Holy Family, " now at Munich,
one of the least graceful of all Raphael's compositions. The "
Entombment of Christ," now in the Galleria Borghese in Rome, was
painted during a visit to Perugia in 1507 for Lady Atalanta Baglioni,
in memory of the death of her brave and handsome but treacherous
son Grifonetto, who was killed in 1 500 by his enemies the Oddi
party.2 The many studies and preliminary sketches3 for this
important picture which exist in various collections show that it cost
Raphael an unusual amount of thought and labour in its
composition, and yet it is quite one of his least successful paintings,
especially in colour. It is, however, much injured by scraping and
repainting, and appears not to be wholly by his hand. The "
Madonna del Baldacchino," one of the finest compositions of the
Florentine period, owing much to Fra Bartolommeo, is also
unsatisfactory in execution; being left unfinished by Raphael, it was
completed by Ridolfo Ghirlandajo, by whom the ungraceful angels of
the upper part and the canopy were wholly executed, and even
designed. It was painted for the Dei family as an altar-piece for their
chapel in S. Spirito, Florence. The " St Catherine " of the National
Gallery was probably painted in 1507; its cartoon, pricked for
transference, is in the Louvre. In colouring it much resembles parts
of the Borghese " Entombment," being quiet and grey in tone. To
the Florentine period belong some of his finest portraits, and it is
especially in these that da Vinci's influence appears. The portraits of
Angelo Doni and his wife Maddalena (Pitti) are vivid and carefully
executed paintings, and the unknown lady with hard features (now
in the Uffizi) is a masterpiece of noble realism and conscientious
finish. The Czartoriski portrait, a graceful effeminate-looking youth
with long hair and tapering hands, now moved to Cracow, is
probably a work of this period; though worthy to rank with Raphael's
finest portraits, its authenticity has been doubted. Very similar in
style is the Herrenhausen portrait, once attributed to Giovanni
Bellini, but an undoubted work of Raphael, in his second manner; it
also represents a young man with long hair, close-shaven chin, a
wide cloth hat and black dress, painted in half-length. The 1 It is
engraved at p. 53, vol. ii., of Dohme, Kunsl und Kilnstier des
Mittelalters (Leipzig, 1878), a work which has many good
reproductions of Raphael's paintings and sketches. 2 See Symonds,
Sketches in Italy, the chapter on Perugia, mainly taken from the
contemporary chronicle of Matarazzo. 3 These show that Raphael at
first intended to paint a Deposition from the Cross, and afterwards
altered his scheme into the Entombment; an excess of study and
elaboration partly account for the shortcomings of this picture. so-
called Portrait of Raphael by himself at Hampton Court is a very
beautiful work, glowing with light and colour, which may possibly be
a genuine picture of about 1506. It represents a pleasant-looking
youth with turned-up nose, not bearing the remotest resemblance to
Raphael, except the long hair and black cap common to nearly all"
the portraits of this time.* A fine but much-restored portrait of
Raphael by himself, painted at Florence, exists in the Uffizi; it
represents him at a very early age, and was probably painted during
the early part of his stay in Florence. Third or Roman Period, 1508-
1520. — In 1508 Raphael was painting several important pictures in
Florence; in September of that year we find him settled in Rome,
from a letter addressed in the warmest terms of affectionate
admiration to Francia, to whom he sent a sketch for his " Adoration
of the Shepherds," and promised to send his own portrait in return
for that which Francia had given him.6 Raphael was invited to Rome
by his fellow-citizen (not relation, as Vasari says) BramaDte, who
was then occupied in the erection of the new church of St Peter, the
foundation-stone of which had been laid by Julius II. on the i8th of
April 1506. At this time the love of the popes for art had already
attracted to Rome a number of the chief artists of Tuscany, Umbria
and North Italy, among whom were Michelangelo, Signorelli,
Perugino, Pinturicchio, Lorenzo Lotto, Peruzzi, Sodoma, and many
others, and it was among this brilliant assembly that Raphael, almost
at once, took a leading position.6 Thanks to Bramante's friendly
intervention, Julius II. (Delia Rovere) soon became Raphael's most
zealous patron and friend, as did also the rich bankers Agostino
Chigi (the Rothschild of his time) and Bindo Altoviti, whose portrait,
at the age of twenty, now at Munich, is one of the most beautiful
that Raphael ever produced. A series of rooms in the Vatican, over
the Appartamenti Borgia, were already decorated with frescoes by
Bonfigli, FIG. 3. — Plan showing position of Raphael's frescoes in the
stanze. A. Stanza della Segnatura (1509-11); I, Disputa; 2, School of
Athens; 3, Justinian giving his code to Trebonian; 4, Gregory IX.
giving decretals to a jurist; 5 (over the window), Three Virtues; 6
(over the other window), Apollo and a group of poets on Mount
Parnassus; vault with medallions of Poetry, Theology, Science, and
Justice, and other paintings. B. Stanza d'Eliodoro (1511-14): 7,
Expulsion of Heliodorus from the Temple; 8, Mass of Bolsena; 9, St
Peter freed from prison; 10, Attila repulsed by Leo I.; vault with
scenes from Old Testament, by pupils. C. Stanza dell' Incendio
(1517). nearly all painted by pupils: n, Burning of the Borgo; 12,
Victory of Leo IV. over the Saracens at Ostia; 13, Coronation of
Charlemagne by Leo III. in St Peter's; 14, Oath of Leo III. before
Charlemagne. D. Sala di Costantino, painted by pupils (1520-24): 15
and 16, oil-paintings of Comitas and Justitia attributed to Raphael;
17, 17, great fresco of the Defeat of Maxentius. E E. Part of
Raphael's loggia, by his pupils. F. Chapel of Nicholas V., painted by
Fra Angelico. G. Cortile of Bramante. Perugino, Piero della Francesca,
Andrea del Castagno, Signorelli and Sodoma; but so rapidly had the
taste of the time changed that Julius II. decided to sweep them all
away and re-cover the 4 To judge of the authorship of a portrait
from internal evidence is especially difficult, as in so many cases the
strong individuality of the person represented obscures that of the
painter. ' Malvasia, Felsina pittrice (Bologna, 1678), was the first to
publish this letter; see also Miintz, Raphael, sa vie, &c., p. 315 (Paris,
1881). Minghetti (Nuova Antologia, 1883) throws doubt on the date
of this letter. • Miintz, " Michel-Ange et Raphael a la cour de Rome,"
Cmz. des B. Arts, March and April 1882, and Les arts a la cour des
popes, vol. iii. (Paris, 1884)
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9°4 RAPHAEL SANZTO walls with paintings in the more

developed but less truly decorative style of Raphael. It was not
without regret that Raphael saw the destruction of this noble series
of frescoes. One vault, that of the Stanza dell' Incendio, painted by
his master Perugino, he saved from obliteration; it still exists, well
preserved, a most skilful piece of decorative work; and he also set
his pupils to copy a number of portrait-heads in the frescoes of Piero
della Francesca before they were destroyed.1 Fig. 3 shows the
positions of Raphael's frescoes in the stanze, which, both from their
size and method of lighting, are very unsuited for the reception of
these large pictures. The two most impoitant rooms ( A and B) are
small, and have an awkward crosslight from opposite windows.2
Stanza della Segnatura (papal signature room), painted in 1509-11
(A on fig. 3). The first painting executed by Raphael in the stanze
was the so-called Disputa, finished in 1509. It is very unlike the later
ones in style, showing the beginning of transition from his Florentine
to his "Roman manner"; as a decorative work it is very superior to
the other frescoes; the figures are much smaller in scale, as was
suited to the very moderate size of the room, and the whole is
arranged mainly on one plane, without those strong effects of
perspective which are so unsuited to the decorative treatment of a
wall-surface. In its religious sentiment, too, it far excels any of the
later stanze paintings, retaining much of the sacred character of
earlier Florentine and Umbrian art. As a scheme of decoration it
appears to have been suggested by some of the early apsidal
mosaics. Fig. 4 shows the disposition of its main masses, which
seem to indicate the curved recess of an apse. Gold is largely used,
with much richness of effect, while the later purely pictorial frescoes
have little or none. The subject of this magnificent painting is the
hierarchy of the church on earth and its glory in heaven.3 The
angels in the upper tier and the nude cherubs who carry the books
of the Gospels are among the most beautiful figures that Raphael
ever painted. The painting on the vault of this room is the next in
date, and shows further transition towards the " Roman manner." In
his treatment of the whole Raphael has, with much advantage, been
partly guided by the painting of Perugino's vault in the next room
(C). Though not without faults, it is a very skilful piece of decora•
tion; the pictures are kept subordinate to the lines of the vault, and
their small scale adds greatly to the apparent size of the whole. A
great part of the ground is gilt, marked with mosaic-like squares, a
common practice with decorative painters — not intended to deceive
the eye, but simply to give a softer texture to the gilt surface by
breaking up its otherwise monotonous glare. The principal
medallions in each cell of this quadripartite vault are very graceful
female figures, representing Theology, Science, Justice, and Poetry.
Smaller subjects, some almost miniature-like in scale, are arranged
in the intermediate spaces, and each has some special meaning in
reference to the medallion it adjoins; some of these are painted in
warm monochrome to suggest bas-reliefs. The fine painting of the "
Flaying of Marsyas " is interesting as showing Raphael's study of
antique sculpture: the figure of Marsyas is a copy of a Roman statue,
of which several replicas exist. The very beautiful little picture of the
" Temptation of Eve " recalls Albert Dtirer's treatment of that subject,
though only vaguely. Much mutual admiration existed between
Raphael and purer: in 1515 Raphael sent the German artist a most
masterly life study of two nude male figures (now at Vienna) ; on it
is written in Albert Diirer's beautiful hand the date and a record of its
being a gift from Raphael. It is executed in red chalk, and was a
study for two figures in the " Battle of Ostia " (see below). On the
wall opposite the Disputa is the so-called School of Athens.4 1 How
fine these portrait-heads probably were may be guessed from Piero's
magnificent frescoes at Arezzo, in the retro-choir of S. Francesco. 2
See Brunn, Die Composition der Wandgemalde Raphaels int Vatican
(Berlin), and Gruyer, Lesfresques de Raphael au Vatican (Paris,
1859). 3 It need hardly be said that the name Disputa is a
misnomer; there could be no dispute among the saints and doctors
of the church about so well-established a dogma as the real
presence: the monstrance with the Host below and the figure of
Christ above indicate His double presence both on earth and in
heaven. Dr Braun, Springer, and Hagen have published monographs
in German on this painting. 4 See Trendelenburg, Vber Rafael's
Schule von Athen (Berlin, 1843), and Richter (same title)
(Heidelberg, 1882) ; the title " School of Athens " is comparatively
modern. FIG. 4 — Diagram to show main lines of the Disputa,
suggesting an apse, with mosaic decoration. In this and the
succeeding frescoes all notion of decorative treatment is thrown
aside, and Raphael has simply painted a magnificent series of
paintings, treated as easel pictures might have been, with but little
reference to their architectural surroundings.' The subject of this
noble fresco, in contrast to that opposite, is " Earthly Knowledge,"
represented by an assembly of the great philosophers, poets and
men of science of ancient Greece. The central figures are Plato and
Aristotle, while below and on each side are groups arranged with the
most consummate skill, including the whole " filosofica famiglia " of
Dante (Infer, iv. 133-144), and a number of other leaders of thought,
selected in a way that shows no slight acquaintance with the history
of philosophy and science among the ancient Greeks. Many
interesting portraits are introduced — Bramante as the aged
Archimedes, stooping over a geometrical diagram; a beautiful fair-
haired youth on the left is Francesco Maria della Rovere, duke of
Urbino; and on the extreme right figures of Raphael himself and
Sodoma are introduced (see fig. 5, below). The stately building in
which these groups are arranged is taken with modifications from
Bramante's first design for St Peter's. Over the window (No. 6 on fig.
3) is a group of poets and musicians on Mount Parnassus, round a
central figure of Apollo; it contains many heads of great beauty and
fine portraits of Dante and Petrarch. The former, as a theologian,
appears also in the Disputa. Over ^he opposite window (No. 5) are
graceful figures of the three chief Virtues, and at one side (No. 4)
Gregory IX. (a portrait of Julius II.) presenting his volume of
decretals to a jurist; beside him is a splendid portrait of Cardinal de'
Medici (afterwards Leo X.) before his face was spoiled by getting too
stout. This painting shows the influence of Melozzo da Forli.6 On the
other side Justinian presents his code to Trebonianus (No. 3) ; this is
inferior in execution, and appears to have been chiefly painted by
pupils. The next room (B), called La Stanza d'Eliodpro, was painted
in I5II-I4;7 it is so called from the fresco (No. 7 in fig. 3)
representing the expulsion of Heliodorus from the Temple (2 Mace.
Hi.), an allusion to the struggles between Louis XII. of France and
Julius II. The whole spirit of the subjects in this room is less broad
and tolerant than in the first: no pagan ideas are admitted, and its
chief motive is the glorification of the pontificate, with insistence on
the temporal power. The main incident of this picture is the least
successful part of it : the angel visitant on the horse is wanting in
dignity, and the animal is poorly drawn, as is also the case with the
horses of Attila's army in the fresco opposite. The group of women
and children on the left is, however, very beautiful, and the figures
of Julius II. and his attendants are most nobly designed and painted
with great vigour. The tall standing figure of Marc Antonio Raimondi,
as one of the pope's bearers, is a marvellous piece of portrait-
painting, as is also the next figure who bears his name on a scroll—
10 . PETRO . DE . FOLIARHS . CREMONlN. Behind, Giulio Romano is
represented as another papal attendant. This picture was completed
in 1512. Over the window (No. 8) is the scene of the Miracle at
Bplsena of 1264, when the real presence was proved to a doubting
priest by the appearance of blood-stains on the Corporal (see
ORVIETO). Julius II. is introduced kneeling behind the altar; and the
lower spaces on each side of the windows are filled with two groups,
that on the left with women, that on the right with officers of the
papal guard. The last group is one of the most masterly of all
throughout the stanze : each face, a careful portrait, js a marvel of
expression and power, and the technical skill with which the whole is
painted to the utmost degree of finish, almost without any tempera
touches, is most wonderful. The next fresco in date (No. 10) is that
of the Repulsion of Attila from the walls of Rome by Leo I.,
miraculously aided by the apparitions of St Peter and St Paul; it
contains another allusion to the papal quarrels with France. It was
begun in the lifetime of Julius II., but was only half-finished at the
time of his death in 1513; thus it happens that the portrait of his
successor, the Medici pope Leo X., appears twice over, first as a
cardinal riding behind' the pope, painted before the death of Julius
II., and again in the character of S. Leo, instead of the portrait of
Julius which Raphael was about to paint.8 Attila with his savage-
looking 6 He has shown great skill in the way in which he has fitted
his end frescoes into the awkward spaces cut into by the windows,
but they are none the less treated in a purely pictorial manner. 6
Compare his fresco of Sixtus IV., now in the picture-gallery of the
Vatican. 7 The vault of this room is painted with scenes from the Old
Testament on a harsh blue ground, much restored; they are
probably the work of Giulio Romano, and in a decorative way are
very unsuccessful — a striking contrast to the beautiful vaults of
Perugino and Raphael in rooms C and A. The deep blue grounds so
much used by Raphael's school are very liable to injury from damp,
and in most cases have been coarsely restored. Those in the Villa
Madama are untouched, and in parts the damp has changed the
ultramarine into emerald green. 8 A pen sketch in the Louvre by
Raphael shows Julius II. in the place afterwards occupied by Leo X.;
another difference in this sketch is that the pope is borne in a chair,
not on horseback as in the fresco.
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RAPHAEL SANZIO 905 army is not the most successful part

of the fresco: the horse-, arcvery wooden in appearance, and the
tight-fitting scale armour, put on in some impossible -way without
any joints, gives a very unreal and theatrical look to the picture. 1
art is the work of pupils. In 1514 he painted the " Deliverance of St
Peter from Prison," with a further political allusion (No. 9). It is very
skilfully arranged to fit in the awkward space round the window, and
is remarkable for an attempt, not much suited for fresco-painting, to
combine and contrast the three different qualities of light coming
from the moon, the glory round the angel, and the torches of the
sentinels. For room C Raphael designed and partly painted the "
Incendio del Borgo" (No. n.i, a fire in the Bongo or Leonine City,
which was miraculously stop|>ed by Leo IV. appearing and making
the sign of the cross at a window in the Vatican. On the background
is shown the facade of the old basilica of St Peter, not yet destroyed
when this fresco was painted. One group on the left, in the
foreground, is remarkable for its vigour and powerful drawing; the
motive is taken from the burning of Troy; a fine nude figure of
/Eneas issues from the burning houses bearing on his back the old
Anchises and leading the boy Ascanius by the hand. Some of the
female figures are designed with much grace and dramatic power.
Many studies for this picture exist. This is the last of the stanze
frescors on which Raphael himself worked. Others designed by him
and painted by Giulio Romano, Gianfranccsco Penni, and other pupils
were the " Battle of Ostia " (No. 12), a very nobly composed picture,
and the " Oath of Leo III. before Charlemagne " (No. 14). The other
great picture in this room (No. 13), the Coronation of Charlemagne "
(a portrait of Francis I. of France), is so very inferior in composition
that it is difficult to believe that Raphael even made a sketch for it.
The enormous fresco of the " Defeat, of Maxentius by Constantino "
(room D, No. 17) was painted by Giulio Romano, soon after
Raphael's death, from a sketch by the latter; it is even more harsh
and disagreeable in colour than most of Giulio Romano's early
frescoes.1 Among the other very inferior frescoes in this great hall
are two female figures (Nos. 15 and 16) representing Comitas and
Justitia, painted on the wall in oil colours, very harmonious and rich
in tone; they are usually, though wrongly, attributed to Raphael
himself. Technical Methods employed in Raphael's Frescoes. —
Having made many studies, both nude and draped, for single figures
and groups, the painter made a small drawing of the whole
composition, which was enlarged by his pupils with the help of
numbered squares, drawn all over it, to the full size required,2 on
paper or canvas. Holes were then pricked along the outlines of the
cartoon, and the design pounced through on to an undercoat of dry
stucco on the wall, with pounded charcoal and a stiff brush. Over
this, early in the morning, a patch of wet stucco was laid, about
enough to serve for the day's painting; this of course obliterated the
outline on the wall, and the part covered by the patch was again
sketched in by freehand, with a point on the wet stucco, so as to be
a guide for the outline traced with the brush and the subsequent
painting. A line impressed on the wet stucco was easily smoothed
out, but a touch of the brush full of pijgment sank deeply into the
moist stucco, and could not easily be effaced. It will thus be seen
that in fresco painting the only use of pouncing the whole design on
to the wall was to keep the general positions of the figures right,
and was no guide as to the drawing of each separate part. Fig. 5
shows the portrait-heads of himself and Perugino (?), at the extreme
right of the School of Athens; on this are visible many of the
impressed sketch-lines, and also part of the " fresco edge " of the
patch on which this part is painted. The heads in this figure are less
than one day's work. It will be seen that there is no attempt at any
accuracy of drawing in the impressed lines. Raphael, especially in his
later frescoes, worked with wonderful rapidity: three life-sized busts,
or half a full-length figure, more than life-size, was a not unusual
day's work. In some of the frescoes the edges of each day's patch of
stucco can easily be traced, especially in the Incendio del Borgo,
which has a strong side light. In the Disputa much use was made of
tempera in the final touches, but less was used in the subsequent
frescoes, owing to his increasing mastery of the difficulties of the
process. The paintings in the stanze were only a small part of
Raphael's work between 1509 and 1513. To this period belong the
Madonna of Foligno (Vatican), painted in 1511 for Sigismondo Conti;
it is one of his most beautiful compositions, full of the utmost grace
and sweetness of expression, and appears to be wholly the work of
his hand. It has suffered much from repainting. Of about the same
date are the gem-like Garvagh Madonna (National Gallery, bought
for £9000; once in the possession of the Aldobrandini family), the
Diademed Virgin 'See Montagnani, Sola di Costantino (Rome, 1834).
Though he was never a good colourist, the great frescoes by Giulio
Romano in the Palazzo del Te, Mantua, show some improvement as
compared with his Roman work. 'These three stages were usually
distinguished as study, sketch and cartoon. of the Louvre, and the
Madonna del Pesce at Madrid. The last is a very noble picture but
the design is more pleasing than the FIG. 5. — Heads of Raphael
and Perugino (?), from the School of Athens, showing incised lines
and " fresco edges." colour, which, like .other paintings of Raphael's
at Madrid, suggests the inferior touch of a pupil; it was executed in
1513 for S. Domenico in Naples. In addition to other easel pictures a
number of his finest portraits belong to this period — that of Julius
II. (Uffizi),3 of which a good replica or contemporary copy exists in
the National Gallery, the so-called Fornarina in the Palazzo Barberini,
the Baldassare Castiglione of the Louvre, and the unfinished portrait
of Federigo Gonzaga of Mantua. When Giovanni de' Medici, at the
age of thirty-eight, became pope as Leo X., a period of the most
glowing splendour and reckless magnificence succeeded the sterner
rule of Julius II. Agostino Chigi, the Sienese financier, was the chief
of those whose lavish expenditure contributed to enrich Rome with
countless works of art. For him Raphael painted, in 1513-14, the
very beautiful fresco of the Triumph of Galatea in his new palace by
the Tiber bank, the Villa Farnesina, and also made a large series of
magnificent designs from Apuleius's romance of Cupid and Psyche,
which were carried out by a number of his pupils.4 These cover the
vault and lunettes of a large loggia (now closed in for protection) ; in
colouring they are mostly harsh and gaudy,6 as is usually the case
with the works of his pupils, a great contrast to the fresco of the
Galatea, the greater part of which is certainly the master's own
work.6 For the same patron he painted (also in 1513) his celebrated
Sibyls 1 A very fine ancient copy of this portrait is in the Pitti Palace;
certain peculiarities in its execution show it to be by some Venetian
painter, as was pointed out to Professor Middleton by Mr Fairfax
Murray. * Chiefly by Giulio Romano, Gianfrancesco Penni and
Giovanni da Udine; much injury has been done to these frescoes by
repainting, especially in the coarse blue of the ground. 6 These and
other frescoes by his pupils are much disfigured by the disagreeable
hot tone of the flesh,- very unlike the pearly tone of the flesh of
Galatea. ' Dorigny, Psychis et Amoris fabula a Raphaele, (fc. (Rome,
1693) ; and Gruner, Fresco Decorations in Italy (London, 1854), pis.
16-18. The group of the Triton and Nymph on the left of the
composition was probably executed by Giulio Romano.
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906 RAPHAEL SANZIO in S. Maria della Pace, — figures of

exquisite grace, arranged with perfect skill in an awkward space. It
is not without reason that Vasari gives these the highest position
among his frescopaintings.1 Agostino Chigi also employed Raphael
to build for him a private chapel in S. Maria del Popolo, and to make
a series of cartoons to be executed in mosaic on the inner dome.2
The central medallion has a figure of God among clouds and angel
boys, FIG. 6. — Mosaic of God creating the stars, from the Chigi
chapel, in centre of dome, designed by Raphael. such as Raphael
drew with unrivalled grace (fig. 6), and around are the eight planets,
each with its pagan deity and directing angel.3 He has not hampered
himself by any of the usual rules which should apply to the designing
of mosaic; they are simply treated as pictures, with almost .
deceptive effects of perspective. The execution of these brilliant
mosaics was carried out by the Venetian Luigi della Pace, whose
signature is introduced on the torch of Cupid in the panel
representing the star Venus (Ludovico della Pace Veneziano fecit,
1516). These mosaics are still as perfect and brilliant as if they were
the work of yesterday. Probably in the early years of Leo X.'s reign
were painted the Madonna della Seggiola (Pitti), the S. Cecilia at
Bologna (not completed till 1516), the miniature Vision of Ezekiel
(Pitti) and three important pictures at Madrid. The latest of these,
known as Lo Spasimo, from the church at Palermo, for which it was
painted, is one of Raphael's finest compositions, representing Christ
bearing His Cross. It bears signs of Giulio Romano's hand in its
heavy colouring with unpleasant purple tones. The Madonna called
Delia Perla has much changed from the darkening of the pigments;
in design it recalls Leonardo da Vinci.4 The small Madonna della
Rosa is the most perfect in colour of all the master's pictures in the
Madrid Gallery, and is usually rather undervalued; it is a most
graceful little picture. The portrait of Leo X. with Cardinals de' Rossi
and de' Medici, in the Pitti, is one of his finest portrait-pictures,
especially as regards the figure of the pope.6 Little is known about
the Madonna di S. Sisto, the glory of the Dresden Gallery; no studies
or sketches for it exist. In style it much resembles the Madonna di
Foligno; it is less injured by restoration than the latter. Among the
latest works of Raphael are the large " St Michael and the Devil," in
the Louvre, signed " Raphael Urbinas pingebat, MDXVIH.," and the
very beautiful portrait of the Violinplayer, in the Sciarra-Colonna
Palace in Rome, also dated 1518; this last bears much resemblance
to the painter himself. The British Museum possesses one of
Raphael's finest portraits, 1 Thanks to Michelangelo's generous
intervention, Raphael was paid the large sum for that time of 900
gold ducats for this fresco. 2 Gruner, Mosaici in S. Maria del Popolo
(Rome, 1839). 3 In accordance with Dante's scheme in the Paradise.
4 La Perla, " the pearl " of the Spanish royal collection, was originally
painted for Bishop Louis of Canossa; it was sold by Cromwell with
the greater part of Charles I.'s collection at Hampton Court. The
composition, though not the execution, of this picture, belongs to
Raphael's early years in Rome; it is very remarkable for its delicacy
of touch and high finish. 6 The magnificent portrait-heads of the
Venetian scholars Navagero and Beazzano, now in the Doria Gallery
in Rome, are worthy of Raphael at his best, and have for lone been
attributed to him. There are good contemporary copies at Madrid.
though only a chalk drawing, that of his friend the painter Timoteo
della Vite, a masterpiece of expression and vigour; it is executed in
black and red, and is but little inferior in chromatic effect to an oil-
painting; it is life size, and is executed with wonderful skill and
evident keen interest in the subject. The tapestry cartoons, seven of
which are in the Victoria and Albert Museum, were painted by pupils
from Raphael's designs. They are part of a set of ten, with scenes
from the Acts of the Apostles, intended, when copied in tapestry, to
adorn the lower part of the walls of the Sistine chapel. The
tapestries themselves, worked at Brussels, are now, after many
vicissitudes, hung in a gallery in the Vatican; the set is complete,
thus preserving the design of the three lost cartoons. The existing
seven, after being cut up into strips for use on the looms, were
bought by Rubens for Charles I.6 The tapestry copies are executed
with wonderful skill, in spite of Raphael's having treated the subjects
in a purely pictorial way, with little regard to the exigencies of textile
work. The designs are reversed, and the colours far more brilliant
than those of the cartoons, much gold and silver being introduced.
The noble figure of Christ in the Delivery of the Keys to St Peter is in
the tapestry much disfigured by the addition of a number of large
gold stars all over the drapery, which spoil the simple dignity of the
folds. The rich framework round each picture, designed by Raphael's
pupils, probably by Penni and Giovanni da Udine, exists in the
tapestries and adds greatly to their decorative effect. The cartoons
were executed in 1515 and 1516, and the finished tapestries were
first exhibited in their place in the Sistine chapel on the 26th of
December 1519 — a very short time for the weaving of such large
and elaborate pictures. The three of which the cartoons are lost
represent the Martyrdom of St Stephen, the Conversion of St Paul,
and St Paul in Prison at Philippi. Probably no pictures are better
known to have been more often engraved and copied than these
seven cartoons.7 The Transfiguration* — In 1519 Cardinal Giuliano
de' Medici (afterwards Clement VII.), as bishop of Narbonne,
ordered two altar-pieces for his cathedral — the one by Raphael, the
other by Raphael's Venetian rival Sebastiano del Piombo. That by the
latter painter is the noble Resurrection of Lazarus, now in the
National Gallery, in the drawing of which the Venetian received
important aid from Michelangelo. Several studies for Raphael's
picture exist, showing that he at first intended to paint a
Resurrection of Christ as a pendant to Sebastiano's subject, but soon
altered his scheme into the Transfiguration. The eight or nine
existing studies are scattered through the Oxford, Lille, Windsor and
sorne private collections. A great part of the lower group was
unfinished at the time of the painter's sudden death in 1520, and a
good deal of the heavy colouring of Giulio Romano is visible in it. On
the death of Raphael the picture became too precious to send out of
Rome, and Cardinal de' Medici contented himself with sending the
Resurrection of Lazarus to Narbonne. The Transfiguration was
bequeathed by him to the monks of S. Pietro in Montorio, in whose
church it remained till it was stolen by Napoleon I. It now hangs in
the Vatican Gallery. Architectural Work? — Though he designed but
few buildings, Raphael's great repute even in this branch of art is
shown by the 6 Fortunately they were not sold with the bulk of
Charles's collection, and remained at Hampton Court till a few years
ago. See Koch, Rafael's Tapeten im Vatican (Vienna, 1878), and
Miintz, Hist, de la tapisserie italienne (Paris, 1880). 7 The name "
arazzi " given by Italians to these tapestries is derived from Arras,
where they were erroneously thought to have been woven; they
were made at Brussels. It is much to be regretted that visitors to the
Vatican are no longer allowed to see these priceless examples of
textile work. 8 See Morgenstern, Vber Rafael's Verkldrung (Leipzig,
1822), and Justi, Die Verklarung Christi (Leipzig, 1870). 'See Ojetti,
Discorso su Ra/aello Architetto (Rome, 1883), but more especially
Geymuller's work mentioned in the text, and his Projets primitifs
pour la Bas. de S. Pierre (Paris, 1875-80); also the works of
Hofmann and Bloch (Dresden, 1900).
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RAPHAEL SANZIO 907 fact that Bramante, before his death

in March 1514, specially requested that Raphael should be made his
successor as chief architect of St Peter's. To this most important post
he was appointed by a brief of Leo X., dated the 1st of August 1514.
The progress of St Peter's was, however, too slow for him to leave
much mark on its design. Another work of Bramante's completed, by
Raphael, was the graceful Cortile di S. Damaso in the Vatican,
including the loggie, which were decorated with stucco- reliefs and
paintings of sacred subjects by his pupils under his own supervision,
but only very partially from his designs.1 The Palazzo dell' Aquila,
built for Giovanni Battista Branconio, and destroyed in the 1 7th
century during the extension of St Peter's, was one of Raphael's
chief works as an architect. He also designed the little cross church,
domed at the intersection like a miniature St Peter's, called S. Eligio
degli Orefici, which still exists near the Tiber, almost opposite the
Farnesina gardens, a work of but little merit. According to M.
Geymiiller, whose valuable work, Raffaello come Architetto (Milan,
1883), has done so much to increase our knowledge of this subject,
the Villa Farnesina of Agostino Chigi, usually attributed to Peruzzi,
was, as well as its palace-like stables, designed by Raphael; but
internal evidence makes this very difficult to believe. It has too much
of the delicate and refined character of the isth century for Raphael,
whose taste seems to have been strongly inclined to the more
developed classic style, of which Palladio afterwards became the
chief exponent. The Palazzo Vidoni, near S. Andrea della Valle, also
in Rome, is usually attributed to Raphael, but an original sketch for
this in Peruzzi's own hand has recently been identified among the
collection of drawings at Siena; this, however, is not a certain proof
that the design was not Raphael's. M. Geymiiller has, however,
shown that the Villa Madama, on the slopes of Monte Mario above
Rome, was really designed by him, though its actual carrying out,
and the unrivalled stuccoreliefs which make its interior one of the
most magnificent palaces in the world, are due to Giulio Romano
and Giovanni da Udine, as mentioned in Vasari's life of the latter.2
The original design for this villa made by Raphael himself has been
discovered by M. Geymuller. Anotherarchitectural work was the little
Chigi chapel in S. Maria del Popolo, built in 1516, for the dome of
which the above-mentioned mosaics were designed (see fig. 6). At
the time of his death he was preparing to build himself a handsome
palace near the church of S. Eligio; the deed for the purchase of its
site was signed by him only a few days before his last short illness.
Though not completed till 1530, the Palazzo Pandolfini at Florence
was also designed by him; it is a dull scholastic building without any
special beauty either in proportion or treatment of the mass; it is
illustrated by Montigny and Famin, Architecture Toscane (Paris,
1815), pis. 33-36. A sober criticism of Raphael's architectural works
must force one to refuse him a high position in this branch of art. In
the church of S. Eligio and the Chigi chapel he is merely a copyist of
Bramante, and his more original works show but little power of
invention or even mastery of the first principles of architectural
design. His details are, however, often delicate and refined
(especially in the Palazzo Pandolfini), and he was supremely
successful in the decorative treatment of richly ornamented interiors
when he did not, as in some of the Vatican stanze, sacrifice the
room to the frescoes on its walls. Sculpture. — That Vasari is right in
attributing to him the model for the beautiful statue of Jonah in the
Chigi chapel (fig. 7) is borne witness to by two important
documents, which show that his almost universal talents led him to
attempt with success the preliminary part of the sculptor's art,
though there is no evidence to show that he ever worked on
marble.' One of these is a letter written to Michelangelo to warn him
that Raphael had been invading his province as a sculptor by
modelling a boy, which had been executed in marble by a pupil, and
was a work of much beauty. Again, after his death his friend
Baldassare Castiglione, in a letter 1 See Mariani, La Bibbia nelle
Loggie del Vaticano (Rome) ; Anon., Dipinti nelle Loggie del Vaticano
(Rome, 1841); and Gruner, Fresco Decorations (London, 1854), pis.
1-5. Too great a share in the decoration of the loggie is usually given
to Raphael; not only the harsh colour but also the feebleness of
much of the drawing shows that he can have had but little to do
with it. 1 See Gruner, Fresco Decorations, &c. (London, 1854), pis.
6-12, and Raffaelle Santi, Ornati della Villa Madama, fire. (Rome,
1875). Two other little known but very beautiful architectural works,
executed under Raphael's influence by his pupils, are the bathroom
of Cardinal Bibbiena in the Vatican and the bathroom of Clement VII.
in the castle of S. Angclo, both richly decorated with delicate stucco-
reliefs and paintings, treated after a classical model. ' See note on p.
369, vol. iv., of Milanesi's edition of Vasari (Florence, 1870). To one
branch of the sculptor's art, practised under Raphael's supervision,
belong the elaborate and delicately executed stucco-reliefs of the
loggie and elsewhere. Among these occur many panels with figure-
subjects, large in scale and important in composition; those
executed during his lifetime are free from the too pictorial character
which is an obvious fault in the very magnificent reliefs of the Villa
Madama. dated the 8th of May 1523, asks his steward in Rome " if
Giulio Romano still possesses a certain boy in marble by Raphael and
what his lowest price for it would be," — " s'egli [Giulio Romano] ha
piu quel puttino di marmo di mano di Raffaello c per quanto si daria
all' ultimo." A group in marble of a Dead Boy on his Dolphin
Playfellow, now in the St Petersburg Hermitage, has been
erroneously supposed to be Raphael's " puttino," which has also
been identified with a statuette of a child formerly at Florence in the
possession of Signer Mohni.4 The statue of Jonah was executed in
marble by Lorenzetto, a Florentine sculptor; and it remained in his
studio for many years after Raphael's death. The Victoria and Albert
Museum possesses a small clay sketch for this beautiful group,
slightly different from the marble; it is probably the original design
by the master's own hand. The whole feeling of the group — a
beautiful youth seated on a sea-monster — is purely classical, and
the motive is probably taken from some antique statue FIG. 7. —
Statue of Jonah in the Chigi chapel, designed by Raphael, sculptured
by Lorenzetto; heroic size. representing Arion or Taras on a dolphin.*
Being intended for a church it was necessary to give the figure a
sacred name, and hence the very incongruous title that it received.
There is no trace of Raphael's hand in the design of the other statue,
an Elijah by Lorenzetto, though it also is ascribed to him by Vasari.
Lesser Arts practised by Raphael. — Like other great artists, Raphael
did not disdain to practise the lesser branches of art: a design for a
silver perfume-burner with female caryatids is preserved in an
engraving by Marco da Ravenna; and he also designed two
handsome reppuss6 salvers for Agostino Chigi, drawings for which
are now at Dresden. In designs for tarsia-work and wood-carving he
was especially skilful; witness the magnificent doors and shutters of
the stanze executed by his pupil Giovanni Barile of Siena.' The
majolica designs attributed to him were by a namesake and relation
called Raffaello di Ciarla;' and, though many fine dishes and ewers of
Urbino and other majolica are decorated with Raphael's designs,
they are all taken from pictures or engravings, not specially done by
him for ceramic purposes. With the frivolity of his age Leo X.
occasionally wasted Raphael's skill on unworthy subjects, such as
the scenery of a temporary theatre; and in 1516 the pope set him to
paint in fresco the portrait life-size of a large elephant, the gift of the
king of Portugal, after the animal was dead.8 This elephant is also
introduced among the stucco reliefs of the Vatican loggie, with the
poetaster Barrabal sitting in mock triumph on its back. Though
Raphael himself does not appear to have practised the art of
engraving, yet this formed one of the many branches of art which
were earned on under his supervision. A large number of his designs
were engraved by his pupils Marcantonio Raimondi and Agostino
Veneziano. These valuable engravings are from Raphael's sketches,
not from his finished pictures, and in some cases they show 4 See
Appendix, p. 406, vol. iv., of Milanesi's edition of Vasari; Rembadi,
Del putto . . . di Raffaello (Florence, 1872); Gennarelli, Sopra una
Scultura di Raffaello (Florence, 1873). The evidence which would
attribute this piece of sculpture to Raphael is almost worthless. See
on the St Petersburg group, Gu&leonoff, Ober die dem Raphael
zugeschr. Marmorgruppe (St Petersburg, 1872). * Compare this
latter subject on reverses of the beautiful didrachms of Tarentum, c.
300 B.C. * The very beautiful and elaborate choir-stalls of the church
of S. Pietrode' Casinensi at Perugia, with panels carved in relief,
executed '" '535 by Stefano da Bergamo, are mainly adapted from
Raphael's designs. 1 Campori, Notizie Star. d. Maiolica di Ferrara (3rd
ed., Pcsaro, 1879), PP- I32-I331 Under it was inscribed — " Raphael
Urbinas quod natura abstulerat arte restituit."
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RAPHAEL SANZIO important alterations made in the

execution of the picture. Raimondi's engraving of the S. Cecilia of
Bologna in design is very inferior to that of the actual painting.
Several of Raphael's most important compositions are known to us
only by these early engravings, e.g. the Massacre of the Innocents
(engraved by Raimondi), which is one of his finest works, both for
skilful composition and for masterly drawing of the nude. Another
magnificent design is the Judgment of Paris, containing a large
number of figures; the nude figure of Minerva is a work of especial
force and beauty. A standing figure of Lucretia1 about to stab herself
is also one of his most lovely figures. Many of Raphael's studies for
Marcantonio's engravings still exist. Archaeology. — As an antiquary
Raphael deserves to take the highest rank. His report2 to Leo X. in
1518 is an eloquent plea for the preservation of ancient buildings. In
1515 he had been appointed by Leo X. inspector of all excavations in
Rome and within 10 miles round. His careful study of the antique,
both statues and modes of decoration, is clearly shown in many of
his frescoes, and especially in the graceful stucco reliefs and painted
grotteschi, of which he and his pupils made such skilful use in the
decorations of the Vatican loggie, the Villa Madama and elsewhere.3
Raphael's Fame. — Among all the painters of the world none has
been so universally popular as Raphael, or has so steadily
maintained his pre-eminent reputation throughout the many changes
in taste which have taken place in the last three and a half centuries.
Apart from his combined merits as a draughtsman, colourist and
master of graceful composition, he owes the constancy of admiration
which has been felt for him partly to the wide range of his subjects,
but still more to the wonderful varieties of his style. If the authorship
of his paintings were unknown, who would guess that the Sposalizio
of the Brera, the Madonna del Baldacchino of the Pitti, and the
Transfiguration could possibly be the work of one painter? In the
seventeen or eighteen years which composed his short working life
he passed through stages of development for which a century would
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