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SLEEP
MEDICINE
PEARLS
SLEEP
MEDICINE
PEARLS
THIRD EDITION

Richard B. Berry, MD
Professor of Medicine
Division of Pulmonary, Critical Care, and Sleep Medicine
University of Florida College of Medicine;
Medical Director
UF Health Sleep Disorder Center
Gainesville, Florida

Mary H. Wagner, MD
Associate Professor of Pediatrics
Division of Pediatric Pulmonary
University of Florida College of Medicine;
Director, Pediatric Sleep Program
UF Health Sleep Disorder Center
Gainesville, Florida
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

Sleep Medicine Pearls ISBN: 978-1-4557-7051-9

Copyright © 2015, 2003, 1999 by Saunders, an imprint of Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in writing from
the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our
arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be
found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as
may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information
provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the
recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of
practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and
the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any
injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Berry, Richard B., 1947- author.
Sleep medicine pearls / Richard B. Berry, Mary H. Wagner. – Third edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4557-7051-9 (hardcover : alk. paper)
I. Wagner, Mary H., author. II. Title.
[DNLM: 1. Sleep Disorders–diagnosis–Case Reports. 2. Sleep Disorders–therapy–Case Reports. 3. Polysomnography–
Case Reports. WL 108] RC547
616.8’498–dc23
2014016503

Content Strategist: Helene T. Caprari

Senior Content Development Specialist: Dee Simpson
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Rachel E. McMullen
Design Direction: Steven Stave

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 This book is dedicated to our families:
David, Sarah, and Catherine Berry
Daniel, Analiese, and Barry Wagner

And to our past and present sleep fellows:

Eric Friskel, MD
Prakash Patel, MD
Kapil Dhawan, MD
Michael Maraist, MD
Sreekala Prabhakaran, MD
Klark Turpen, MD
Ashish Prasad, MD
Emily Beck, MD
Anil Puri, MD
Robert Tilley, MD
Lubna Al Hourani, MD
Holly Skinner, DO
Malini Dondapati, DO
 Preface

It has been 10 years since the 2nd edition of Sleep now an integral part of a growing number of sleep
Medicine Pearls was published. Since that time centers. These and many other changes provide
the field of Sleep Medicine has changed tremen- more that ample justification for updating the
dously. Digital polysomnography has completely previous edition of Sleep Medicine Pearls. The
replaced recording on paper, the American Acad- basic format has been very popular with readers
emy of Sleep Medicine Manual for the Scoring of and case based instruction is now used in many
Sleep and Associated Events has been published sleep medicine texts.
and revised. The International Classification of We have been encouraged by numerous
Sleep Disorders, 2nd edition was published and readers of the previous editions to update the
publication of the third edition by early 2014 is text. There are many fine textbooks on sleep
planned. Board certification in Sleep Medicine medicine. The goal of Sleep Medicine Pearls is
is now available through member boards of the to concisely introduce the basic knowledge
American Board of Medical Specialties. Limited needed to take care of patients with sleep disor-
channel sleep testing outside of sleep centers ders using short didactic fundamentals chapters
(Out of Center Sleep Testing) is now acceptable followed by case presentations illustrating use
for the diagnosis of obstructive sleep apnea in of the information provided. It is beyond the
adults. New modes of positive airway pressure scope of this textbook to cover every aspect of
treatment are available to treat patients with sleep medicine. Topics thought to be most rele-
hypoventilation or central apnea due to vant to clinical practice are included. Updating
Cheyne-Stokes breathing or opioids. New treat- all of the chapters to reflect the explosion of
ments for the restless legs syndrome have knowledge in sleep medicine has been a formida-
appeared and the importance of augmentation ble task. In addition nearly all of the figures in the
with dopaminergic medications has been recog- previous text have been updated to contain the
nized. Our knowledge of the causes of narcolepsy new montages and sensors recommended for
and circadian sleep wake rhythm disorders has sleep recording. Many new figures have been
increased and use of actigraphy is a growing part added. It is hoped that the reader will find the
of most sleep medicine practices. The behavioral new edition informative and useful.
treatment of insomnia has been established as an
effective method for treatment of insomnia and is Richard B. Berry, MD

vi
 Video Contents

1. REM Sleep Behavior Disorder 1

2. REM Sleep Behavior Disorder 2
3. Head Banging
4. Periodic Limb Movements in Sleep
5. Obstructive Sleep Apnea
6. Confusional Arousal
7. Bruxism
8. Sleepwalking
9. Sleep Terror in 20-year-old Female

xii
 FUNDAMENTALS 1

Sleep Stage Nomenclature and

Basic Monitoring of Sleep

Sleep is divided into non–rapid eye movement TIME WINDOW FOR

(NREM) and rapid eye movement (REM) sleep.
From 1968 until 2007, sleep was usually staged STAGING SLEEP
according to A Manual of Standardized Terminol-
ogy, Techniques, and Scoring System for Sleep Stages Digital polysomnography (sleep recording) allows
of Human Subjects, edited by Rechtschaffen and visualization of the waveforms in multiple time
Kales (R&K).1 In the R&K Scoring Manual, windows (10, 15, 30, 60, 90, 120, and 240 seconds)
(Table F1-2). A 30-second window is used to stage
NREM sleep was divided in stages 1, 2, 3, and
sleep (known as an epoch), whereas a 10-second
4. REM sleep was referred to as stage REM. Sleep
window is used for clinical electroencephalogra-
stage nomenclature has changed following
phy (EEG) monitoring. A 10-second window
the publication of the American Academy of
allows for detailed visualization of waveforms to
Sleep Medicine (AASM) Manual for the Scoring of
determine frequency. The convention of using a
Sleep and Associated Events (hereafter referred to
30-second window for sleep staging is based on
as the AASM Scoring Manual) in 2007.2,3 To
paper recording using ink pens during the early
denote sleep staging by new criteria, sleep stage
days of sleep monitoring. At a page speed of
nomenclature has changed. The old and new
nomenclatures are shown in Table F1-1. Stages 10 millimeters per second (mm/s), a standard
30-centimeter (cm) page of recording paper repre-
3 and stage 4 are combined into stage N3.
sented 30 seconds. Each page represented one
REM sleep is referred as stage R. An update of
the AASM Scoring Manual has recently been pub- epoch. Sleep is still staged today in sequential
30-second epochs, although digital polysomno-
lished, but sleep stage nomenclature remains
graphy allows for use of different time windows
unchanged.4
for scoring respiratory and other events.
Sleep staging is based on electroencephalog-
raphy (EEG), electrooculography (EOG), and
submental (chin) electromyography (EMG) cri- Electroencephalography Monitoring
teria. EOG (eye movement recording) and chin
EMG recordings are used to detect stage R, EEG monitoring to detect and stage sleep requires
which is characterized by rapid eye movements only a portion of the electrodes used for clinical
(REMs) and reduced muscle tone. EEG monitoring. The nomenclature for EEG

TABLE F1-1 Sleep Stage Nomenclature TABLE F1-2 Optimal Window Duration
for Viewing Events in
R&K AASM Polysomnography
Wake Stage W Stage W
Window Duration Use
NREM Stage 1 Stage N1
30 seconds (an epoch) Sleep staging
Stage 2 Stage N2
60–120 seconds Respiratory Events
Stage 3 Stage N3
15 seconds Clinical EEG
Stage 4
10 seconds ECG rhythms
REM Stage REM Stage R
Identifying wave form
AASM, American Academy of Sleep Medicine; NREM, frequency
non–rapid eye movement; REM, rapid eye movement;
R&K, Rechtschaffen and Kales. ECG, Electrocardiography; EEG, electroencephalography.

1
2 FUNDAMENTALS 1 SLEEP STAGE NOMENCLATURE AND BASIC MONITORING OF SLEEP

electrodes follows the International 10-20 sys- difference between them (e.g., Input-1 ! Input-2).
tem.5 In this system, even-numbered subscripts By convention, a change in the voltage difference
refer to the right side of the head and odd- between Input-1 and Input-2 results in an upward
numbered subscripts to the left. Electrodes are deflection if Input-1 is NEGATIVE with respect
named for the part of the brain they cover: F to Input-2 (see Figure F1-3). Of note, the term
for frontal, C for central, and O for occipital channel is used to describe each horizontal display
(Figure F1-1). The central midline (vertex) elec- of a given signal versus time (each line of the dis-
trodes (Cz) and the frontopolar midline electrode play). Sometimes, an EEG derivation is referred
(Fpz) are also of interest. The Fpz position is often to as a channel. However, a given channel may
used for the ground electrode and the Cz position display other signals, for example, the air flow
for the reference electrode. Note that before pub- channel or the chest effort channel.
lication of the AASM Scoring Manual, electrodes
M1 and M2 were referred to as A1 and A2, respec-
tively. In clinical EEG monitoring, A1 and A2 are, Recommended
in fact, referred to as earlobe electrodes.
The “10-20” in the International 10-20 system Electroencephalography
of nomenclature for EEG electrodes refers to the Derivations
fact that the electrodes are positioned at either The EEG derivations and backup derivations
10% or 20% of the distance between landmarks.5 recommended by the AASM Scoring Manual
The major landmarks include the nasion (bridge are presented in Table F1-3. All of the elec-
of the nose), inion (prominence at base of the trodes—F3, F4, C4, C3, O1, O2, M1, M2—are
occiput), and preauricular points (Figure F1-2). recorded, although display of only the recom-
mended derivations is required for sleep staging.
Electroencephalography Of historical interest, in the R&K Scoring
Manual, only central derivations were used
Derivations to stage sleep. Note that each of the recom-
EEG recording uses differential alternating cur- mended derivations uses a frontal, central, or
rent (AC) amplifiers, which are designed to occipital electrode and the opposite mastoid
amplify the difference in voltage between elec- electrode. If the electrode F4 is faulty, the der-
trodes. There is cancellation of signals common ivation F3-M2 is used. The derivations C4-M1
to both electrodes (common mode rejection). and O2-M1 are used along with F3-M2. The
(Figure F1-3), this type of AC amplifier group of electrodes chosen for visualization is
allows the recording of relatively low-voltage called the montage. Digital polysomnography
EEG activity superimposed on a background of allows for display of all or only a subset of the
higher-voltage electrical noise. The term deriva- possible derivations using the electrodes that
tion describes a pair of electrodes and the voltage are recorded.

FIGURE F1-1 n Nomenclature and position of the basic electrodes for sleep monitoring. C, Central; F, frontal;
O, occipital. Even numbers on the right and odd on the left. (Adapted from Berry RB: Fundamentals of sleep medicine,
Philadelphia, 2012, Saunders, pp. 2-3.)
 FUNDAMENTALS 1 SLEEP STAGE NOMENCLATURE AND BASIC MONITORING OF SLEEP 3

Vertex
Cz
20% 20%
20% F
4
C4 20%
20%
10% 20%
10%
10% O2 10% Nasion

Inion
FIGURE F1-2 n Electrode posi- Preauricular
tions using the international M2 point
10-20 system. Electrodes are
placed at 10% or 20% of the
distance between landmarks.
(Adapted from Berry RB: Funda-
mentals of sleep medicine, Phila-
delphia, 2012, Saunders, pp. 2-3.)

If Input-1 is negative compared Differential amplifier

to Input-2 the deflection is upward Common mode rejection

– 20 – 60!V
Input-1 – 30!V – 40!V Input-1 – 20!V
Output Output
0 0
Input-2 Input-2

+10
FIGURE F1-3 n Differential alternating current (AC) amplifiers amplify the difference in signals at the inputs. Common
signals are not amplified as they cancel (common mode rejection). In the figure, the gain or amplification factor
is " 1 for simplicity. By convention, if Input-1 is negative with respect to Input-2, the deflection is upward. (Adapted
from Berry RB: Fundamentals of sleep medicine, Philadelphia, 2012, Saunders, p. 14.)

TABLE F1-3 Recommended and Backup

Electroencephalography
Derivations
Recommended Backup

F4-M1 F3-M2
C4-M1 C3-M2
O2-M1 O1-M2

FIGURE F1-4 n Placement of recommended electroocu-

ELECTROOCULOGRAPHY lography (EOG) electrodes and EOG derivations.
MONITORING OF SLEEP For comparison, previous typical locations and deri-
vations are presented on the right. A1 and A2 are
older terminology for left and right mastoid electrodes.
Recording of eye movements is possible because (Adapted from Berry RB: Fundamentals of sleep medicine,
a potential difference exists across the eyeball Philadelphia, 2012, Saunders, p. 7.)
with the front (cornea) positive (+) and back (ret-
ina) negative (!). Eye movements are detected Previously, eye electrodes were named right outer
by EOG recording of voltage changes associated canthus (ROC) and left outer canthus (LOC).1,6,7
with eye movement by using electrodes posi- Note that E1 is placed below the left outer canthus
tioned near the eyes. The recommended EOG and E2 is placed above right outer canthus, whereas
electrodes in the AASM Scoring Manual2 are LOC and ROC were placed slightly lateral to the
illustrated in Figure F1-4. E1 and E2 refer to respective outer canthus. Because E1 is below the
the left and right eye electrodes, respectively. eyes and E2 is above the eyes, vertical as well as
4 FUNDAMENTALS 1 SLEEP STAGE NOMENCLATURE AND BASIC MONITORING OF SLEEP

horizontal movements can be detected. The E2

Look Look
AASM Scoring Manual recommends the EOG der- left right
ivations E1-M2 and E2-M2 (see Figure F1-4). # " " #
Note that both eye derivations use the right mas-
toid electrode (M2) as the reference electrode. E1
" #
When the eyes move toward an electrode, a
positive voltage is recorded. Recall that, by con- E1 –M2
vention, if Input-1 is positive with respect to
Input-2, then a downward deflection occurs in # "
the derivation Input-1 ! Input-2. Thus, eye E2 –M2
movement (cornea +) toward an eye electrode
referenced to another electrode further away E1 positive to M2, E1 negative to M2,
from the eyes results in a downward deflection. deflection down deflection up

Using the recommended EOG derivations, eye E2 negative to M2, E2 positive to M2,
movements result in out of phase deflections deflection up deflection down
in the two derivations. This is because eye FIGURE F1-5 n Lateral eye movement with the result-
movements are conjugate, and when both eyes ing deflections in the recommended electroocu-
move laterally or vertically, they both move lography (EOG) derivations. When the eyes move
toward the EOG electrodes, the deflection is down-
toward one EOG electrode and away from the ward. (Adapted from Berry RB: Fundamentals of sleep
other EOG electrode. The polarity of the eye medicine, Philadelphia, 2012, Saunders, p. 7.)
electrodes determines the net voltage difference
of the EOG derivations, as the electrodes are
much closer to the eyes than M2. The schematic are discussed in more detail in Fundamentals 2.
in Figure F1-5 illustrates lateral eye movements The recommended eye derivations make it easier
and the resulting deflections. This assumes that to recognize artifacts or EEG activity transmit-
both eye derivation tracings are displayed with ted to the eye derivations, as these cause in-
negative polarity upward (standard). phase deflections, whereas eye movements
During eyes-open wakefulness and REM cause out-of-phase deflections. In Figure F1-6,
sleep, the associated eye movements are charac- a large-amplitude EEG wave (K-complex
terized by narrow (sharp) EOG deflections, and [KC]) causes in-phase deflections in the EOG
are called rapid eye movements (REMs). The slow derivations, whereas REM results in out-of-
undulating eye movements of drowsiness (eyes- phase deflections. KC and other wave forms
closed wakefulness) and stage N1 are called slow important for sleep staging are discussed in
eye movements (SEMs). Eye movement patterns Fundamentals 2.

FIGURE F1-6 n A K-complex (KC) causes in-phase deflections in the derivations E1-M2 and E2-M2, whereas a rapid
eye movement (REM) causes an out-of-phase deflection. The chin electromyography (EMG) activity falls just before
an REM is noted and a transition from NREM to REM sleep occurs.
 FUNDAMENTALS 1 SLEEP STAGE NOMENCLATURE AND BASIC MONITORING OF SLEEP 5

CHIN (SUBMENTAL) (point A) at the transition to Stage R (just before

REMs occur) is shown. However, chin EMG
ELECTROMYOGRAPHY often reaches the REM level during NREM
MONITORING sleep well before the transition to stage R. Of
note, the reduction in chin EMG amplitude
The placement of EMG electrodes recommended during REM sleep is a reflection of the general-
by the AASM Scoring Manual is illustrated in ized skeletal muscle hypotonia present in this
Figure F1-7. The revised AASM Scoring manual sleep stage.
defines the position and nomenclature of the chin
electrodes (Figure F1-7). ChinZ refers to the mid-
line electrode above the mandible and Chin1 and REVIEW QUESTIONS
Chin2 refer to the electrodes below the mandible
on the patient’s left (Chin1) and right (Chin2). 1. If electrode C4 fails in the recommended EEG
The recommended derivations are either derivations F4-M1, C4-M1, and O2-M1 what
Chin1-ChinZ or Chin2-ChinZ. The electrode EEG derivations should be used?
not used in the displayed derivation is placed as A. F4-M1, C3-M1, O2-M1
a backup. For example, if the Chin1 electrode is B. F4-M1, C3-M2, O2-M1
faulty the derivation Chin2-ChinZ is used for C. F3-M2, C3-M2, O1-M2
staging. If ChinZ is faulty, ideally it should be D. F4-M2, C3-M2, O2-M2
replaced. If this is not feasible, the derivation
Chin1-Chin2 can be used. 2. The deflection in the derivation F4-M1 is
The monitoring of chin EMG activity is an downward. This means:
essential element only for identifying stage R A. F4 is positive with respect to M1
(REM sleep). In stage R, chin EMG is relatively B. F4 is negative with respect to M1
reduced, that is, the amplitude is equal to or
lower than the lowest chin EMG amplitude dur- 3. When the eyes move toward the right, this
ing NREM sleep. Chin EMG amplitude during causes:
other sleep stages is variable. Depending on the A. An upward deflection in E2-M2
EMG gain, a reduction in EMG amplitude from B. A downward deflection in E2-M2
wakefulness to sleep and often a further reduc-
tion on transition from stage N1 to stage N2 to
stage N3 may be seen. A further drop may be
seen on transition from NREM to REM sleep. ANSWERS
In Figure F1-6, a fall in chin EMG amplitude
1. B
Three electrodes are recommended to record the chin EMG
2. A

3. B

ChinZ
REFERENCES
Chin2 Chin1 1. Rechtschaffen A, Kales A (eds): A manual of standardized
terminology techniques and scoring system for sleep stages of
human sleep, Los Angeles, 1968, Brain Information Ser-
ChinZ Electrode Midline 1 cm above inferior edge of mandible
vice/Brain Research Institute, University of California,
Los Angeles.
Chin2 Electrode 2 cm below inferior edge of the mandible and 2. Iber C, Ancoli-Israel S, Chesson A, Quan SF, for the
2 cm to the right of the midline American Academy of Sleep Medicine: The AASM manual
Chin1 Electrode 2 cm below inferior edge of mandible and for scoring of sleep and associated events: rules, terminology and
2 cm to the left of the midline technical specifications, ed 1, Westchester, IL, 2007,
American Academy of Sleep Medicine.
Standard chin EMG derivations Chin1 – ChinZ or Chin2 – ChinZ
3. Silber MH, Ancoli-Israel S, Bonnet MH, et al: The visual
FIGURE F1-7 n Positions of the recommended chin elec- scoring of sleep in adults, J Clin Sleep Med 15:121–131,
trodes as specified in the American Academy of Sleep 2007.
Medicine (AASM) Manual for the Scoring of Sleep and 4. Berry RB, Brooks R, Gamaldo CE, et al., for the
Associated Events. The standard chin derivation is American Academy of Sleep Medicine: The AASM
either of the electrodes below the mandible referred manual for the scoring of sleep and associated events: rules,
to the midline electrode above the manual. (Adapted from terminology and technical specifications, Version 2.0,
Berry RB: Fundamentals of sleep medicine, Philadelphia, Darien, IL, 2012, American Academy of Sleep Medicine
2012, Saunders, p. 9.) Accessed June 1, 2014.
6 FUNDAMENTALS 1 SLEEP STAGE NOMENCLATURE AND BASIC MONITORING OF SLEEP

5. International Federation of Societies for Electroencepha- 7. Caraskadon MA, Rechtschaffen A: Monitoring and stag-
lography and Clinical Neurophysiology: Ten-twenty ing human sleep. In Kryger MH, Roth T, Dement WC
electrode system, Electroencephalogr Clin Neurophysiol (eds): Principles and practice of sleep medicine, Philadelphia,
10:371–375, 1958. 2005, Saunders, p. 1.
6. Berry RB: Fundamentals of sleep medicine, Philadelphia, PA,
2012, Elsevier, pp. 1–26.

PATIENT 1

EEG Derivations and Eye

Movements
A 15-second tracing of a patient undergoing sleep monitoring is shown in Figure P1-1. The two ques-
tions refer to the figure.

QUESTIONS
1. The eye movements at A and B (rapid eye movements) in Figure P1-1 result in out of phase deflec-
tions in the two electrooculography (EOG) derivations (one up–one down). Assuming that the eye
movement at B is a vertical eye movement, is the direction up or down?

2. What is the deflection at C in Figure P1-1 called?

FIGURE P1-1 n A 15-second trac-

ing. Rapid eye movements are
noted at A and B.
6 FUNDAMENTALS 1 SLEEP STAGE NOMENCLATURE AND BASIC MONITORING OF SLEEP

5. International Federation of Societies for Electroencepha- 7. Caraskadon MA, Rechtschaffen A: Monitoring and stag-
lography and Clinical Neurophysiology: Ten-twenty ing human sleep. In Kryger MH, Roth T, Dement WC
electrode system, Electroencephalogr Clin Neurophysiol (eds): Principles and practice of sleep medicine, Philadelphia,
10:371–375, 1958. 2005, Saunders, p. 1.
6. Berry RB: Fundamentals of sleep medicine, Philadelphia, PA,
2012, Elsevier, pp. 1–26.

PATIENT 1

EEG Derivations and Eye

Movements
A 15-second tracing of a patient undergoing sleep monitoring is shown in Figure P1-1. The two ques-
tions refer to the figure.

QUESTIONS
1. The eye movements at A and B (rapid eye movements) in Figure P1-1 result in out of phase deflec-
tions in the two electrooculography (EOG) derivations (one up–one down). Assuming that the eye
movement at B is a vertical eye movement, is the direction up or down?

2. What is the deflection at C in Figure P1-1 called?

FIGURE P1-1 n A 15-second trac-

ing. Rapid eye movements are
noted at A and B.
 PATIENT 1 EEG DERIVATIONS AND EYE MOVEMENTS 7

Eyes toward E1 Eyes away from E1

+ deflection down – deflection up
FIGURE P1-2 n Vertical eye movements cause out-of-phase
deflections in the recommended EOG derivations (E1-M2 Eyes away from E2 Eyes toward E2
and E2-M2). – deflection up + deflection down

ANSWERS
1. Assuming A and B are vertical eye movements, the eye movement is upward.
Discussion: In Figure P1-1 an upward deflection in E1-M2 means that the eyes are moving away
from E1, for example, in an upward direction (see Fundamentals 1). The downward deflection in
E2-M2 means the eyes are moving toward E2 (upward). The effect of vertical eye movements on
tracings in the recommended EOG derivations is illustrated in Figure P1-2. Recall that the cornea
of the eye is positive with respect to the retina. When the eyes move toward an EOG electrode, the
deflection is downward. Because eye movements are conjugate (both eyes move in the same direc-
tion horizontally or vertically), both eyes move toward one EOG electrode and away from the other
using the recommended derivations E1-M2 and E2-M2. Therefore, both horizontal and vertical
movements result in out-of-phase deflections. As a consequence, it is not possible to tell if the eyes
are moving vertically or horizontally.

2. The deflection at C is called eye movement artifact but is simply the recording of voltage changes
associated with the vertical eye movements in F4-M1.
Discussion: The deflection in F4-M1 at C in Figure P1-1 is associated with the rapid eye move-
ment at B. The deflection at C is sometimes called eye movement artifact but is not really an artifact as
the voltage change associated with the eye movement is recorded in a derivation using F4, which is
located near the eyes. Such deflections may be quite large, especially with voluntary eye movements.
Note that the minimal deflection in C4-M1 and none in O2-M1 are associated with the eye move-
ment (C4 and O2 are more distant from the eyes). If both F4-M1 and F3-M2 derivations are dis-
played (Figure P1-3), it is possible to detect the direction of eye movements. As both frontal
electrodes are above the eyes, vertical eye movements result in in-phase deflections in F3-M2
and F4-M1. Out-of-phase deflections in the frontal derivations mean that the eye movements
are horizontal. The tracing if Figure P1-3 shows in-phase deflections in the two frontal derivations,
that is, the eye movement is vertical. Downward deflections in F4-M1 and F3-M2 document that
both eyes move toward both frontal electrodes (upward movement). Note that minimal to no
deflection in the frontal derivations was associated with the rapid eye movement at A. This could
be because the eye movement was downward (further away from the frontal electrodes) or resulted
in only a small voltage change in the frontal derivations. Not all movements are associated with
distinct deflections in the frontal derivations.
The AASM scoring manual2–4 provides an acceptable set of EOG electrode locations and derivations
(Figure P1-4). Note that the nomenclature of the acceptable electrodes is the same as the recom-
mended electrodes (E1, E2) but the locations for acceptable E1 and E2 are different, and both electrodes
are below the eyes and slightly lateral to the respective outer canthus. Both electrodes are referred to
8 FUNDAMENTALS 1 SLEEP STAGE NOMENCLATURE AND BASIC MONITORING OF SLEEP

FIGURE P1-3 n A 15-second tracing

of the patient in the previous
figure with F3-M2 substituted for
C4-M1. As the deflections (C) in
both frontal derivations associ-
ated with the eye movement (B)
are in phase this means that the
eye movement is vertical. A down-
ward deflection means the eyes
are moving toward the electrodes
F3 and F4 (upward).

F4 F3
Fpz

E2 E1
FIGURE P1-4 n Acceptable electrooculography (EOG) elec-
trodes and EOG derivations. (AASM Scoring Manual). Note
that although the same nomenclature (E1 and E2) is used
to refer to EOG electrodes in both the recommended and
acceptable EOG derivations, the positions of the acceptable
EOG electrodes are different. Acceptable E1 and E2 elec-
trodes are located below and slightly lateral to the left and
right outer canthus, respectively.

TABLE P1-1 Eye Movements in the Recommended and Acceptable Derivations1,3

EOG
Derivations Vertical Eye Movements Horizontal Eye Movements K-Complex

Recommended E1-M2 Out-of-phase deflections Out-of-phase deflections In-phase deflections

E2-M2
Acceptable E1-Fpz In-phase deflections Out-of-phase deflections In-phase deflections
E2-Fpz

the frontopolar midline electrode Fpz. In these EOG derivations (E1-Fpz, E2-Fpz) vertical eye
movements are associated with in-phase deflections and horizontal eye movements with out-of-
phase deflections (Table P1-1). With vertical eye movements, the eyes move toward or away from
both EOG electrodes. With horizontal eye movements the eyes move away from one EOG elec-
trode and toward the other EOG electrode, resulting in out-of-phase deflections.
An advantage of the acceptable EOG derivations (E1-Fpz, E2-FPz) is that they are more sen-
sitive for detecting vertical eye movements such as blinks compared with the recommended
EOG derivations. The vertical distance separating the recommended E1 (or E2) electrode from
 PATIENT 1 EEG DERIVATIONS AND EYE MOVEMENTS 9

M2 is much smaller than that between the acceptable E1 (or E2) and electrode and Fpz. Hence
vertical eye movements are associated with larger deflections in E1-Fpz and E2-Fpz compared with
the recommended EOG derivations.

CLINICAL PEARLS
1. Conjugate eye movements (both eyes move left or right or up or down) result in out-of-phase deflections in
the recommended EOG derivations E1-M2 and E2-M2.
2. Eye movements may cause deflections in the frontal derivations (“eye movement artifact”).
3. The American Academy of Sleep Medicine (AASM) Scoring Manual also defines acceptable EOG deriva-
tions with both E1 and E2 below and lateral to the respective outer canthus. Using E1-Fpz and E2-Fpz, ver-
tical eye movements are characterized by in-phase deflections and horizontal movements by out-of-phase
deflections (see Table P1-1).

REFERENCES
1. Iber C, Ancoli-Israel S, Chesson A, Quan SF, for the American Academy of Sleep Medicine: The AASM manual for scoring of
sleep and associated events: rules, terminology and technical specifications, ed 1, Westchester, IL, 2007, American Academy of Sleep
Medicine.
2. Silber MH, Ancoli-Israel S, Bonnet MH, et al: The visual scoring of sleep in adults, J Clin Sleep Med 15:121–131, 2007.
3. Berry RB, Brooks R, Gamaldo CE, et al: for the American Academy of Sleep Medicine: The AASM manual for the scoring of sleep
and associated events: rules, terminology and technical specifications, Version 2.1, Darien, IL, 2012, American Academy of Sleep
Medicine. www.aasmnet.org, Accessed June 1, 2014.
4. Berry RB: Fundamentals of sleep medicine, Philadelphia, 2012, Saunders.
 FUNDAMENTALS 2

Electroencephalography and
Electrooculography Patterns
of Interest for Staging Sleep

Recognition of certain characteristic electroen- Sleep spindles arise from thalamocortical oscilla-
cephalography (EEG) patterns is essential for tions. The reticular nucleus of the thalamus is
sleep staging (Figure F2-1; Table F2-1).1–3 responsible for generating sleep spindles.
EEG activity is described by frequency in cycles A K-complex (KC) is a high-amplitude
per second (hertz [Hz]), amplitude (microvolts biphasic wave composed of an initial negative
[mV]), and shape. Activity with a higher fre- sharp wave (deflection up) followed by a slow
quency results in narrower deflections, and wave. A burst of spindle activity is often superim-
slower frequency results in wider deflections. posed on a KC. The KC stands out from the lower
The classically described EEG frequency ranges voltage background. KC activity is greatest in fron-
are delta (0–4 Hz), theta (4–8 Hz), alpha tal derivations (also central > occipital). A KC is
(8–13 Hz), and beta (>13 Hz). Sharp waves said to be associated with an arousal if the arousal
are narrow waves of 70 to 200 milliseconds commences no more than 1 second after the KC.
(msec) duration, and spikes have a shorter dura- An arousal during sleep stages N1, N2, and N3 is
tion of 20 to 70 msec. The distribution of EEG scored if an abrupt shift of EEG frequency occurs,
activity (the derivations in which the activity is including alpha, theta, and/or frequencies greater
most prominent) and the effects of eye opening than 16 Hz (but not spindles) that lasts at least
or closure are also important for some types of 3 seconds, with at least 10 seconds of stable sleep
EEG activity. preceding the change. Arousals are discussed in
The term alpha activity is used to describe any more detail in Fundamentals 5. Note that the
EEG activity with a frequency in the alpha range KC is seen in the EOG derivations E1–M2 and
(8–13 Hz). However, alpha rhythm consists of E2–M2 as an in-phase deflection (see Funda-
alpha activity that is most prominent in occipital mentals 1, Figure F1-6).
derivations (see Figure F2-1) and is attenuated by Slow wave activity is a defining characteristic
eye opening (increased by eye closure). Another of stage N3 sleep. As noted previously, the fre-
term for alpha rhythm is posterior dominant quency of delta activity is 0 to 4 Hz. EEG activity
rhythm (PDR). Alpha rhythm is characteristic in this range produces relatively wide duration
of eyes closed stage W. Alpha activity may be deflections, often called delta or slow waves (see
noted during stage R and is often associated with Figure F2-1). However, for sleep staging, the
brief awakenings (arousals). Bursts of alpha activ- designation slow wave activity (SWA)2 specifi-
ity are common in stage R. cally refers to waves with a frequency range of 0.5
Sleep spindles and K complexes (KCs) are defining to 2 Hz (2- to 0.5-second duration) and a peak-
characteristics of stage N2 sleep. Sleep spindles1–3 to-peak amplitude greater than 75 mV in the fron-
are bursts of activity with a frequency range of tal derivations (see Figure F2-1). When SWA is
11 to 16 Hz (usually 12–14 Hz) with a duration 20% of an epoch stage or greater, N3 is scored.
of 0.5 seconds or greater (usually 0.5–1.5 sec- Slow waves have the greatest amplitude over
onds). The term spindle is used because the shape frontal areas. In the Rechtschaffen and Kales
of sleep spindle burst is often like that of a yarn (R&K) definitions, only central derivations were
spindle. If uncertainty exists about whether activ- utilized for sleep staging. Because slow wave
ity is a burst of alpha activity or a sleep spindle, a amplitude is higher over the frontal areas com-
10-second window may be displayed and the pared with central areas, a given epoch of EEG
deflections (waves) per second actually counted. activity would potentially have greater SWA

10
 FUNDAMENTALS 2 ELECTROENCEPHALOGRAPHY AND ELECTROOCULOGRAPHY 11

Slow waves

K complex sawtooth waves

F4-M1

C4-M1
sleep spindle

O2-M1

alpha
E1-M2

E2-M2

Chin

1 sec

FIGURE F2-1 n Electroencephalography (EEG) waveforms used to stage sleep.

TABLE F2-1 Summary of Important Wave Forms for Sleep Staging

Alpha Activity (Alpha Rhythm)
8–13 hertz (Hz).
Most prominent over the occipital areas (alpha rhythm).
Activity increased by eye closure and attenuated by eye opening (alpha rhythm).
Characteristic electroencephalography (EEG) activity in drowsy, eyes-closed stage W
(alpha rhythm).
Common in rapid eye movement (REM) sleep (1–2 Hz slower than during stage W).
May occur with arousals (brief awakenings).
10% of persons do not produce alpha rhythm with eye closure.

Sleep Spindle
11–16 Hz (classically 12–14 Hz).
Maximal over central areas.
Duration !0.5 sec (0.5–1.5 sec).
One of the defining characteristics of stage N2.
Thalamocortical oscillations (reticular thalamic nucleus).
May be seen in stage N3 sleep.
Drug spindles (benzodiazepines) may have a slightly faster frequency.

K-Complex (KC)
High amplitude–biphasic deflection.
A well-delineated negative sharp wave (upward) followed by a positive (downward) slow wave.
Stands out from the lower voltage background.
Duration !0.5 sec.
Characteristic of stage N2 sleep.
Maximal over frontal areas (frontal > central> occipital).
KC–associated arousal requires arousal to start no more than 1 second after KC termination.

Slow Waves (Slow Wave Activity [SWA])

Frequency 0.5–2 Hz and >75 microvolts (mV) peak-to-peak amplitude in the frontal
derivations.
Used to define stage N3 sleep.
Stage N2 <20% SWA (<6 sec).
Stage N3 !20% SWA (! 6 sec).
SWA is usually transmitted to eye derivations.

Continued
12 FUNDAMENTALS 2 ELECTROENCEPHALOGRAPHY AND ELECTROOCULOGRAPHY

TABLE F2-1 Summary of Important Wave Forms for Sleep Staging—Cont’d

Sawtooth Waves
Trains of triangular waves, often serrated.
2–6 Hz waves.
Maximal in amplitude in central derivations.
Often, but not always, preceding a burst of REMs.
Characteristic of stage R but not required for scoring stage R.

Vertex Sharp Wave

Sharply contoured waves.
Duration <0.5 sec.
Maximal over the central region (derivations containing C3, C4, Cz) and distinguishable
from the background activity (higher amplitude).
Occurs in stage N1 often near transition to stage N2 (and also in stage N2).

(longer duration meeting amplitude criteria)

BOX F2-1 Eye Movements Pattern
using the American Academy of Sleep Medicine
Definitions
(AASM) Scoring Manual definition2 (frontal der-
ivations) compared with the R&K definition Eye blinks: Conjugate vertical eye movements at a
(using central derivations). It is not surprising frequency of 0.5 to 2 hertz (Hz) present in wake-
that sleep staging using the AASM Scoring Man- fulness with the eyes open or closed.
ual shows a result of slightly more stage N3 sleep Reading eye movements: Trains of conjugate eye
(as a percentage of total sleep time). movements consisting of a slow phase followed
Vertex sharp waves are narrow duration waves by a rapid phase in the opposite direction as
the subject reads.
(<500 msec according to the AASM Scoring
Slow eye movements: Conjugate, fairly regular,
Manual2) prominent in derivations containing sinusoidal eye movements with an initial deflec-
electrodes near the vertex (Cz, C3, C4). They tion lasting >500 milliseconds (msec).
are often seen near the transition between stage Rapid eye movements (REM): Conjugate, irreg-
N1 and stage N2 sleep. Sawtooth waves (see ular, sharply peaked eye movements with an ini-
Figure F2-1) occur during rapid eye movement tial deflection usually lasting <500 msec. While
(REM) sleep, although they are not always pre- rapid eye movements are characteristic of stage R
sent during this sleep stage. They are triangular sleep, they may also be seen in wakefulness with eyes
waves of 2 to 6 Hz of highest amplitude in the open (as patients look around the room).
central derivations. The presence of sawtooth
Adapted from the AASM Scoring Manual.1,3
waves is not required to score stage R. However,
the presence of sawtooth waves, when they
occur, is very helpful. eye movements that are a mixture of slow and
The key points concerning EEG waveforms more rapid activity that persists into stage
used to stage sleep are summarized in N2.4,5 This pattern is called Prozac eyes but
Table F2-1. may occur with any of the SSRIs.
Blinks are vertical eye movements that occur
usually during wakefulness but may occur during
EYE MOVEMENT sleep. They are typically short in duration, less
ELECTROOCULOGRAPHY PATTERNS than 0.5 seconds. Knowledge about the Bell phe-
nomenon is helpful in understanding the pattern
Typical eye movement patterns (Box F2-1; of blinks or changes in the EOG with eyes open-
Figure F2-2) include blinks, slow eye movements ing or closing. The Bell phenomenon consists of
(SEMs), rapid eye movements (REMs), and read- a reflex upward movement of the eye globe with
ing eye movements. Slow eye movements are eye lid closure. With eye opening, the globe
typical of eyes-closed drowsiness and wakeful- returns to a neutral position. A blink, then, con-
ness and also may occur in stage N1 sleep. REMs sists of eye movement upward with a return to
are seen in eyes-open wakefulness and stage R neutral. The movement away from E1 results
sleep. SEMs typically disappear with the onset in an upward deflection in E1-M2 and toward
of stage N2 sleep. However, patients on selective E2 results in a downward deflection in E2-M2
serotonin reuptake inhibitors (SSRIs) may have (Figure F2-3). As an upward deflection causes
 FUNDAMENTALS 2 ELECTROENCEPHALOGRAPHY AND ELECTROOCULOGRAPHY 13

FIGURE F2-2 n Eye movement

patterns—15 second tracings.
(Adapted from Berry RB: Funda-
mentals of sleep medicine, Phila-
delphia, 2012, Saunders, p. 9.)

the eyes to be closer to E2, blinks may be of a observation of the patient reading on the syn-
greater amplitude in E2-M2 than in E1-M2 chronized video recorded with the sleep study.
and may also cause deflections in the frontal Reading eye movements display a pattern of a
derivations. slow gaze to the right (reading from left to right)
Recognition of the pattern of reading eye followed by a fast deflection to the left (to begin
movements (Figure F2-4) is assisted by reading the next line of print). The resulting

E2
E2 E2

FIGURE F2-3 n The electrooculog- E1

raphy (EOG) pattern of blinks, eye E1 E1
E1
closure, and eye opening is
understood by knowledge of the E1-M2 E1-M2
E1-M2
Bell phenomenon. When the
eye lids close, the eye globe E2-M2 E2-M2 E2-M2
turns upward.

eyes quick return

scan leftward
rightward to begin next line
FIGURE F2-4 n The etiology of the
pattern of reading eye move-
ments. The eyes move slowly
to the right while reading a line
of print and then move rapidly upward deflection in E1-M2 downward deflection in E1-M2
leftward to start a new line. downard deflection E2-M2 upward deflection E2-M2
14 FUNDAMENTALS 2 ELECTROENCEPHALOGRAPHY AND ELECTROOCULOGRAPHY

pattern is predictable, based on slow eye move- 2. Silber MH, Ancoli-Israel S, Bonnet MH, et al: The visual
ment to the right (reading from left to right) scoring of sleep in adults, J Clin Sleep Med 15:121–131, 2007.
3. Berry RB, Brooks R, Gamaldo CE, et al: for the American
and then rapid eye movement leftward to begin Academy of Sleep Medicine: The AASM manual for
a new line. the scoring of sleep and associated events: rules, terminology and tech-
nical specifications, Version 2.3, Darien, IL, 2012, American
Academy of Sleep Medicine. Accessed June 1, 2014.
4. Schenck CH, Mahowlad MW, Kim SW, et al: Prominent
REFERENCES eye movements during NREM sleep and REM sleep
1. Iber C, Ancoli-Israel S, Chesson A, Quan SF, for the behavior disorder associated with fluoxetine treatment
American Academy of Sleep Medicine: The AASM manual of obsessive-compulsive disorder, Sleep 15:226–235, 1992.
for scoring of sleep and associated events: rules, terminology 5. Armitage R, Trivedi M, Rush AJ: Fluoxetine and oculo-
and technical specifications, ed 1, Westchester, IL, 2007, motor activity during sleep in depressed patients, Neurop-
American Academy of Sleep Medicine. sychopharmacology 12:159–165, 1995.

PATIENT 2

Eye Movements, Alpha Rhythm, and

Sleep Spindles in a 20-Year-Old Man
A 20-year-old man undergoes a sleep study for a history of daytime sleepiness and snoring. Figures P2-1
and P2-2 are 15-second and 6-second tracings, respectively.

QUESTIONS

1. Biocalibrations are a series of maneuvers that a patient performs while awake, before lights out, in
response to technologist instructions. At “A” in Figure P2-1, was the command “eyes open” or
“eyes closed”?

FIGURE P2-1 n A 15-second tracing

during biocalibration.
14 FUNDAMENTALS 2 ELECTROENCEPHALOGRAPHY AND ELECTROOCULOGRAPHY

pattern is predictable, based on slow eye move- 2. Silber MH, Ancoli-Israel S, Bonnet MH, et al: The visual
ment to the right (reading from left to right) scoring of sleep in adults, J Clin Sleep Med 15:121–131, 2007.
3. Berry RB, Brooks R, Gamaldo CE, et al: for the American
and then rapid eye movement leftward to begin Academy of Sleep Medicine: The AASM manual for
a new line. the scoring of sleep and associated events: rules, terminology and tech-
nical specifications, Version 2.3, Darien, IL, 2012, American
Academy of Sleep Medicine. Accessed June 1, 2014.
4. Schenck CH, Mahowlad MW, Kim SW, et al: Prominent
REFERENCES eye movements during NREM sleep and REM sleep
1. Iber C, Ancoli-Israel S, Chesson A, Quan SF, for the behavior disorder associated with fluoxetine treatment
American Academy of Sleep Medicine: The AASM manual of obsessive-compulsive disorder, Sleep 15:226–235, 1992.
for scoring of sleep and associated events: rules, terminology 5. Armitage R, Trivedi M, Rush AJ: Fluoxetine and oculo-
and technical specifications, ed 1, Westchester, IL, 2007, motor activity during sleep in depressed patients, Neurop-
American Academy of Sleep Medicine. sychopharmacology 12:159–165, 1995.

PATIENT 2

Eye Movements, Alpha Rhythm, and

Sleep Spindles in a 20-Year-Old Man
A 20-year-old man undergoes a sleep study for a history of daytime sleepiness and snoring. Figures P2-1
and P2-2 are 15-second and 6-second tracings, respectively.

QUESTIONS

1. Biocalibrations are a series of maneuvers that a patient performs while awake, before lights out, in
response to technologist instructions. At “A” in Figure P2-1, was the command “eyes open” or
“eyes closed”?

FIGURE P2-1 n A 15-second tracing

during biocalibration.
 PATIENT 2 EYE MOVEMENTS, ALPHA RHYTHM, AND SLEEP SPINDLES 15

2. What are the names of the waveforms A and B in Figure P2-2? The short black lines are
1-second long.

FIGURE P2-2 n A 6 second tracing

is shown. The short dark lines are
1 second in duration.

ANSWERS
1. Answer: “Eyes open”
Discussion: To the left of “A,” the eyes were closed with prominent alpha rhythm. Alpha rhythm
has a frequency of 8 to 13 Hz, is most prominent in occipital derivations, and is attenuated with eye
opening. After “A” alpha rhythm is attenuated and you can also see rapid eye movements (REMs)
consistent with eyes-open stage W. A more general term for a rhythm that is most prominent in
occipital areas and attenuated by eye opening is posterior dominant rhythm. It is important to review
the biocalibrations to determine if the individual generates alpha rhythm with eye closure. As will be
discussed in Fundamentals 3, the rules for scoring stage W and stage N1 are different if an indi-
vidual does not generate alpha rhythm with eye closure. Note that at “A,” a large upward deflection
occurs in F4-M1 derivation. Recall that when the eyes lids are closed, the globe turns upward.
With eye opening, the eye moves downward (away from F4), and this results in a positive deflection
in F4-M1.

2. Answer: The activity at A is alpha rhythm. The activity at B is a sleep spindle.

16 FUNDAMENTALS 2 ELECTROENCEPHALOGRAPHY AND ELECTROOCULOGRAPHY

FIGURE P2-3 n A 10-second window allows counting of the deflections in a wave

form in 1 second to determine the frequency.

Discussion: At times, distinguishing alpha rhythm from sleep spindles may be challenging. Some
overlap exists in the frequency range (alpha 8 to 13 hertz [Hz] and sleep spindles 11 to 16 Hz).
Although alpha rhythm is typically present at the transition from wake to sleep, bursts of alpha
activity may occur during epochs of sleep. Bursts of alpha activity are especially common during
stage R, and the frequency is often 1 to 2 Hz slower than during wakefulness. Bursts of alpha activity
also commonly occur during arousal from sleep (brief awakenings). Sleep spindles are characteristic
of stage N2 but may also be noted in stage N3. Although the sleep spindle frequency range is 11 to
16 Hz, the activity is usually 12 to 14 Hz. Sleep spindle activity may also be superimposed on a
K-complex (KC). A KC with sleep spindle activity may be mistaken for a KC associated with an
arousal (with associated alpha activity). It is helpful to remember that alpha rhythm is most prom-
inent in the occipital derivations, whereas sleep spindle activity is more prominent in central or
frontal derivations.
In Figure P2-2, the activity at A is most prominent in the occipital derivation and has a frequency
of 8 to 9 Hz (within the 8 to 13 Hz alpha range) consistent with alpha rhythm. The activity at B is a
sleep spindle. This activity is faster 12 to 13 Hz (within the 11 to 16 Hz sleep spindle range) and
most prominent in the central derivation (also prominent in frontal derivation).1–3
If the frequency of the activity of a waveform is in doubt change to a 10-second page with the
1-second lines visible.4 The number of oscillations in 1 second may be counted (Figure P2-3).
In Figure P2-3, the waveform frequency is 9 Hz and therefore consistent with alpha activity
(8 to 13 Hz).

CLINICAL PEARLS
1. To determine the frequency of a waveform, switch to a 10-second view with 1-second lines visible, and count
the oscillations in 1 second.
2. The frequency range of alpha rhythm and sleep spindles overlap. Alpha rhythm is most prominent in the
occipital areas and attenuated by eye opening. Sleep spindles are most prominent in the central or frontal
derivations and occur in short bursts.
3. Alpha rhythm is a specific type of alpha activity most prominent in occipital derivations and attenuated by
eye opening.
4. Review of biocalibrations prior to reading a sleep study is important to determine if the individual generates
alpha rhythm with eye closure.

REFERENCES
1. Iber C, Ancoli-Israel S, Chesson A, Quan SF , for the American Academy of Sleep Medicine: The AASM manual for scoring of
sleep and associated events: rules, terminology and technical specifications, ed 1, Westchester, IL, 2007, American Academy of Sleep
Medicine.
2. Berry RB, Brooks R, Gamaldo CE, et al., for the American Academy of Sleep Medicine: The AASM manual for the scoring of
sleep and associated events: rules, terminology and technical specifications, Version 2.1, Darien, IL, 2012, American Academy of Sleep
Medicine. www.aasmnet.org, Accessed July 3, 2014.
3. DeGennaro L, Ferrara M: Sleep spindles: an overview, Sleep Med Rev 7:423–440, 2003.
4. Berry RB: Fundamentals of sleep medicine, Philadelphia, 2012, Saunders, pp. 1–26.
 FUNDAMENTALS 3

Sleep Staging in Adults I

The American Academy of Sleep Medicine (AASM) OVERVIEW OF SLEEP STAGES

Manual for the Scoring of Sleep and Associated
Events1,2 was published in 2007 (subsequently The rules of scoring sleep are detailed and a
referred to as the AASM Scoring Manual). This brief overview is helpful (Table F3-1). During
manual changed the rules of staging sleep and wakefulness, individuals make the transition from
made recommendations about the methods used full alertness to the early stages of drowsiness. The
to monitor sleep. Previously, sleep was staged characteristics of stage W depend on whether an
according to the manual edited by Rechtschaffen individual has the eyes open or closed. During
and Kales (R&K).3 A recent update to the scoring eyes-open wakefulness, the EEG consists of alpha
manual has been published, but relatively few (8–13Hz) and beta (>13 hertz [Hz]) frequencies,
changes have been made in the rules for scoring and the electrooculography (EOG) may demon-
sleep.4 The manual is on-line and periodically strate blinks, voluntary REMs, or reading eye
revised. The reader should review the latest movements (Figure F3-2). Chin electromyogra-
version. The definitions of the electroencephalog- phy (EMG) activity is usually relatively high com-
raphy (EEG) and eye movement patterns used for pared with sleep. As individuals become drowsy,
staging sleep are discussed in Fundamentals 2. blink frequency decreases, and the eyes close. Fol-
This chapter provides an overview of sleep stages lowing eye closure, alpha rhythm is the predomi-
and specific rules for scoring stage W, N1, N2, nant pattern (>50% of the epoch) and slow eye
and N3. See Fundamentals 4 for scoring stage R. movements (SEMs) may be present (Figure F3-3).
On transition to stage N1, low-amplitude
mixed-frequency (LAMF) EEG activity replaces
SLEEP CYCLES alpha rhythm for the majority of the epoch.
LAMF activity is characterized by predominantly
In staging sleep, it is important to keep in mind 4 to 7 Hz activity. The SEMs that may be present
that sleep occurs in cycles of non–rapid eye move- in stage W often persist into stage N1. Chin
ment (NREM) and rapid eye movement (REM) EMG in stage N1 is variable but usually lower
sleep (Figure F3-1). The first epoch of sleep in than stage W. Stage N1 is usually brief, as the
adults is typically stage N1. As the night pro- transition from stage N1 to stage N2 occurs
gresses, less stage N3 occurs, and the duration quickly after sleep onset unless sleep is disturbed
of stage R episodes increases. The number of by frequent brief awakenings (arousals). Episodes
REMs per epoch of stage R (REM density) also of stage N1 may also occur following periods of
increases in the second part of the night. Brief epi- wakefulness during the night (see Figure F3-1).
sodes of wakefulness also occur during the night. About 10% of individuals do not generate
alpha rhythm on eye closure, and a further
Hypnogram 1 Stage R (REM)
10% may generate limited alpha rhythm. The
scoring of stage W and stage N1 sleep in these
W individuals is different compared with alpha gen-
Sleep stage

R erators and is discussed in detail below. The

N1 onset of stage N2 is characterized by the pres-
N2 ence of sleep spindles, K-complexes (KCs), or
N3 both, but these waveforms may not be present
A B C in every epoch of this sleep stage. As noted in
23 24 1 2 3 4 5 6 7 8 the scoring rules, once an epoch of stage N2 is
FIGURE F3-1 n A hypnogram showing normal sleep in a scored, this sleep stage is considered to continue
young adult is shown. until evidence of a transition to another stage of

17
18 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I

TABLE F3-1 Overview of Sleep Stage Characteristics

EEG EOG Chin EMG
Stage W (eyes open) Alpha + beta REMs, blinks, reading EM Relatively high
Stage W (eyes closed) >50% alpha + SEMs Variable
Stage N1 <50% alpha + SEMs Variable, usually < wake
>50% LAMF
Stage N2 SS, KC* None Variable
Stage N3 SWA > 20% (6 sec) None Variable
SS may occur
Stage R LAMF, no SS or KC REMs* Lowest of night

KC, K complex; LAMF, low amplitude mixed frequency; REM, rapid eye movement; Reading EM, reading eye movements;
", may or may not be present; SS, sleep spindle; SEM, slow eye movement; SWA, slow wave activity.
*Characteristic but not in all epochs

FIGURE F3-2 n A 15-second tracing of eyes-open wakefulness with rapid eye movements (REMs) and blinks. Note
that electroencephalography (EEG) shows high-frequency activity. In this individual, blinks are noted in F4-M1
and E2-M2, but not in E1-M2. As the eyes turn upward during blinks (Bell phenomenon), they are closer to E2
and F4 than E1. (see Fundamentals 2).

sleep or a brief awakening (arousal) is seen. As 20% or more of an epoch (! 6 seconds). SWA
stage N2 continues, an increasing amount of is noted in the EOG derivations, and sleep spin-
slow wave activity (SWA) is usually noted dles may be superimposed on the slow waves.
(0.5–2 Hz, peak to peak amplitude >75 micro- An abrupt transition from stage N3 to stage R
volts [mv] over the frontal areas) but occupies may occur, or the SWA (and EEG amplitude)
less than 20% of the epoch (6 seconds). Eye may decrease sufficiently so that stage N3 transi-
movement activity has usually ceased during stage tions briefly into stage N2 before the onset of
N2, and chin EMG is variable in amplitude. stage R. A reduction in SWA, chin EMG activity,
Stage N3 is scored when SWA activity occupies or both is a clue that stage R may soon occur.
 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I 19

FIGURE F3-3 n A 15-second tracing of stage W (eyes closed) in an individual generating alpha rhythm with eye clo-
sure. Note that the alpha rhythm is most prominent in the occipital derivation and present for the entire 15 seconds.
Subtle slow eye movements are also noted.

Epochs of definite stage R are characterized by by alpha rhythm most prominent in the occipital
the absence of sleep spindles or K complexes derivations (see Figure F3-3). Stage W is scored
and the presence of REMs and low chin EMG when rhythmic alpha activity is present in the
activity. However, REMs do not occur in every occipital derivations for more than 50% of the
epoch, and chin EMG may reach REM levels dur- epoch (Table F3-2). SEMs may be present,
ing NREM sleep before REMs appears. Specific and chin EMG activity is variable but usually
rules exist for the start and continuation of stage with a higher amplitude than during sleep.
R. Also, scoring rules exist to deal with the occur- In individuals who do not generate alpha
rence of arousals (brief awakenings) that interrupt rhythm with eye closure, the occipital EEG acti-
an episode of REM sleep. vity is similar during eye opening and eye closure.
The EEG of stage W in non–alpha generators
(both eyes open and closed) consists of a low
amplitude mixture of alpha and higher frequen-
SCORING BY EPOCHS cies (similar to eyes-open wakefulness in alpha
generators). In non–alpha generators, stage W
Sleep is staged in sequential 30 second epochs.
is scored with evidence of wakefulness based on
Each epoch is assigned a sleep stage. If two or
more stages coexist during a single epoch, the
epoch is assigned the stage comprising the great-
est portion of the epoch. Note that any time the TABLE F3-2 Rules for Scoring Stage W
individual being monitored is unhooked from the
monitoring equipment during the night (e.g., trips Score epochs as stage W when more than 50% of
to the bathroom), this time is considered to be stage W. the epoch contains EITHER (a) or (b) or BOTH:
a. Alpha rhythm (posterior dominant rhythm) over
the occipital region (individuals generating
alpha rhythm with eye closure)
STAGE W (WAKEFULNESS) RULES b. Other findings consistent with stage W (all
individuals)
i. Eye blinks (0.5 to 2 Hz)
The EEG of eyes-open stage W in alpha gener- ii. Rapid eye movements associated with
ators consists of a low amplitude mixture of alpha normal or high chin muscle tone
and higher frequencies (see Figure F3-2). The iii. Reading eye movements
EEG of eyes-closed wakefulness is characterized
20 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I

eye movements associated with eyes-open wake- Scoring Manual states that stage N1 occurs at
fulness, including blinks, reading eye movements, the earliest occurrence of any of the following:
or REMs in association with normal or increased SEMs, an EEG with LAMF activity showing a
chin EMG activity (Table F3-2). slowing of the background EEG frequencies by
The current version of the AASM scoring 1 Hz or greater from that in stage W, or the pres-
manual addresses epochs containing a mixture ence of vertex sharp waves (Table F3-3). If SEMs
of alpha rhythm and eye movement patterns of start in the last half of an epoch, then the epoch
wakefulness. An epoch is scored as stage W if would be scored as stage W, but the next epoch
more than 50% contains alpha, eye movements would be staged N1 (assuming no evidence of
associated with wakefulness or both. N2 exists). As noted in the AASM Scoring Manual,
as SEMs may occur before alpha attenuation in
subjects who make alpha activity, the onset of
stage N1 may be scored somewhat earlier (based
STAGE N1 on the appearance of SEMs) in individuals who do
In individuals who generate alpha rhythm on eye not produce alpha activity with eye closure com-
pared with those that do so. As stage N1 is usually
closure, stage N1 is scored when the alpha rhythm
the first stage of sleep in adults, this means that the
in the EEG is attenuated for more than 50% of
sleep latency (lights out to the first sleep) is shorter
the epoch and replaced by LAMF (4–7 Hz) activ-
in non–alpha generators. No specific rules exist
ity (N1 rules Table F3-3) (Figures F3-4 and
for the end of stage N1, as this stage ends when
F3-5). SEMs may occur. Chin EMG is variable
epochs meet criteria for other sleep stages W,
but usually lower than during wakefulness. In
general, sleep spindles (SS) and KCs not associated N2, N3, or stage R.
with arousals are absent. The exception is at the
transition between stage N1 and stage N2. The
final epoch of stage N1 may contain KCs or SSs STAGE N2
in the last half of the epoch. At the transition to
stage N2, vertex sharp waves may appear in stage In scoring stage N2, KC with (KC+A) and with-
N1 and continue during early stage N2. out (KC-A) an associated arousal are treated very
In individuals who do not produce alpha activ- differently. Arousal rules are discussed in detail
ity with eye closure, sleep onset (typically stage in Fundamentals 5. An arousal is scored during
N1) is more difficult to determine. The AASM NREM sleep if an abrupt shift of EEG frequency,
including alpha, theta, and frequencies greater than
16 Hz (but not spindles), lasts at least 3 seconds, with
at least 10 seconds of stable sleep preceding the change
TABLE F3-3 Stage N1 Rules (Figure F3-6). A KC is said to be associated with
an arousal if the arousal commences no more
1. In individuals who generate alpha rhythm, score
stage N1 if the alpha rhythm is attenuated and than 1 second after the termination of the KC.
replaced by low-amplitude, mixed-frequency For simplicity, in the discussion below, KC will
activity for more than 50% of the epoch. be used to denote a K-complex not associated with
2. In individuals who do not generate alpha an arousal.
rhythm, score stage N1 commencing with the
earliest of ANY of the following phenomena:

a. EEG activity in range of 4–7 Hz with slowing Start of Stage N2

of background frequencies by ≥ 1 Hz from
those of stage W
Start scoring stage N2 when one or more KCs
b. Vertex sharp waves (not associated with an arousal) or trains of sleep
c. Slow eye movements spindles (SS) occur in the first half of the cur-
rent epoch or the last half of the previous
Notes: epoch (Figure F3-7). This assumes that the epoch
1. Slow eye movements may occur in stage N1 does not meet criteria for stage N3. Epochs of
but are not required for scoring stage N1
2. Slow eye movements are evidence for stage N1 stage N2 contain less than 20% of slow wave
in non-alpha generators activity (0.5–2 Hz, >75 mV peak-to-peak in frontal
3. The chin EMG tone in stage N1 is variable but derivations). Most digital polysomnography
usually lower than stage W (PSG) systems allow display of amplitude grid lines
4. Low amplitude mixed frequency activity (LAMF)
is low amplitude EEG activity with frequencies
and placing lines at #37.5 mv + 37.5 mv in F4-M1 or
of 4 to 7 Hz F3-M2 allows one to easily note greater than 75 mv
peak-to-peak activity in F4-M1 (Figure F3-8;
Adapted from the AASM Scoring Manual. Table F3-4).
 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I 21

FIGURE F3-4 n Stage N1. A 30 second epoch of stage N1 showing low-amplitude, mixed-frequency electroencephalog-
raphy (EEG) output without K-complexes or sleep spindles. Slow eye movements (SEMs) are prominent here but are
not required for scoring stage N1. In individuals who do not generate alpha on eye closure, the presence of slow eye
movements is a criteria for scoring stage N1. Note the activity at (T) is theta activity of 5 hertz (Hz) (theta is 4–8 Hz).

FIGURE F3-5 n The first 15 seconds of the epoch in F3-F4 is shown here. The electroencephalography (EEG) activity in
the last second is theta activity. This figure shows the appearance of stage N1 as seen on a large screen monitor.

FIGURE F3-6 n A K-complex associated with an arousal. An arousal is scored during non–rapid eye movement
(NREM) sleep if an abrupt shift of EEG frequency, including alpha, theta, and or frequencies greater than 16 Hz
(but not spindles), lasts at least 3 seconds, with at least 10 seconds of stable sleep preceding the change.
22 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I

K complex
K complex Low amplitude Low amplitude K complex associated with arousal
mixed frequency mixed frequency

FIGURE F3-7 n Start of stage N2: Schematics show the start and continuation of stage N2. A K complex associated
with an arousal does not signal the start or the presence of stage N2.

FIGURE F3-8 n Stage N2: A 30-second epoch with sleep spindles (SS) and K-complexes (KCs). The dark horizontal bars
at the top denote the presence of slow wave activity (>75 microvolts [mV] peak to peak, 0.5–2.0 hertz [Hz] in frontal
areas). The total duration of slow wave activity is less than 6 seconds. The dotted lines in F4-M1 are 75 mV apart.

Continuation and End of Stage N2 arousal depends on whether the arousal occurs
in the first or second half of an epoch. In
Stage N2 continues until it is necessary to score an Figure F3-9, an arousal occurs in epoch 201. As
end of a period of stage N2 sleep. Epochs with the arousal occurs in the last half of the epoch,
LAMF EEG activity (without KC or SS) that fol- the current epoch remains as stage N2, but the
low an epoch with sleep spindles or KCs (not next epoch is scored as stage N1. Stage N2
associated with arousal) continue to be scored as resumes only in the presence of a KC not associ-
stage N2 (Table F3-4). If an arousal occurs, a ated with an arousal or sleep spindle (using rules
major body movement (MBM) is followed by SEMs for the start of stage N2, rule N2-A).
(signaling a transition to stage N1), or the epoch
meets criteria for stages W, N3, or R, then stage
N2 ends. MBMs in Fundamentals 5. End of Stage N2: Effect of Major
Body Movement
End of Stage N2: Effects of Arousals A major body movement (MBM) is defined as
When an arousal occurs in stage N2 sleep, this movement and muscle artifact obscuring the
signals a transition of sleep stage (Figure F3-9). EEG for more than half an epoch to the extent
The scoring of the epoch containing the that the sleep stage cannot be determined. If an
 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I 23

TABLE F3-4 Stage N2 Rules

N2-A Rule defining the start of N2 sleep:
EEG: Begin Scoring stage N2 (in the absence of evidence of N3, SWA is <6 seconds) if either or both of
the following occur during the first half of the current epoch or the last half of the previous epoch:
One or more K complexes unassociated with arousals, or
One or more trains of sleep spindles.
EEG: If the only K-complexes present are associated with arousal continue to score Stage N1.
EOG: Usually no eye movements, slow eye movements have ended.
Chin EMG: Variable usually less than wakefulness.
Note: Slow wave activity (SWA) ¼ EEG activity 0.5 to 2 hertz (Hz) with >75 mv peak-to-peak amplitude in
the frontal areas. If SWA >20% of the epoch (!6 seconds), score stage N3.
N2-B Rule defining the continuation of stage N2 sleep:
Continue to score epochs with low-amplitude, mixed-frequency (LAMF) EEG activity without
K-complexes or sleep spindles as stage N2 if they are preceded by an epoch containing either of the
following:
a. K-complexes unassociated with arousals.
b. Sleep spindles.
N2-C Rule defining the end of a period of stage N2 sleep:
End stage N2 sleep when one of the following events occurs:
a. Transition to stage W, stage N3, or stage R.
b. An arousal (change to stage N1 until a K-complex unassociated with an arousal, or a sleep spindle
occurs).
c. A major body movement is followed by slow eye movements and LAMF EEG without non-arousal
associated K-complexes or sleep spindles, then score epochs following the major body movement
as stage N1.
If no slow eye movements follow the major body movement, score the epoch as stage N2.
The epoch containing the body movement is scored using criteria for major body movements.

Adapted from AASM scoring manual. See later rules for arousal and major body movement rules.
EEG, Electroencephalography; EOG, electrooculography.

Arousal Arousal

FIGURE F3-9 n An arousal interrupts stage N2. The epoch containing the arousal is scored, based on the position of
the arousal. Compare epochs 201 and 301.

episode of stage N2 is interrupted by an MBM the MBM epoch is scored as stage W, and stage
epoch, the scoring of subsequent epochs depend N2 ends. If the MBM epoch is followed by an
on the MBM rules (see Fundamentals 5) and SEM (evidence of transition to a lighter stage
stage N2 rules (N2-C-c) (Figure F3-10). If the of sleep), then a transition to stage N1 is scored.
epoch with the MBM has any alpha activity, If the MBM is not followed by an SEM, stage N2
24 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I

Low amplitude Low amplitude

K complex mixed frequency K complex K complex K complex mixed frequency

No alpha No alpha Alpha

A B C
FIGURE F3-10 n A major body movement (MBM) interrupts stage N2 (Stage N2 Rule C.1.c). If the epoch containing the
MBM has no alpha and no slow eye movements (SEMs) occur in the subsequent epoch, stage N2 continues (Epochs
202-203). However, if SEMs follow the MBM, a transition to stage N1 is scored (Epochs 302). If the MBM epoch con-
tains alpha, the epoch is scored as stage W (see MBM rules). In this case, stage N2 ends. The next epoch of sleep
without K-complexes or sleep spindles is scored as stage N1 (unless there is evidence of another sleep stage).

continues. The scoring of the MBM epoch itself epoch does not meet criteria for stage W or stage
is as follows: As noted above, the MBM epoch is R. The scoring rules for stage N2 are summa-
scored as stage W if it contains any alpha activity. rized in Table F3-5.
If the epochs preceding or following the MBM
are scored as stage W, then the MBM epoch is STAGE N3
scored as stage W. If the MBM epoch does not
contain alpha activity and is not preceded or fol- Stage N3 is scored when the amount of SWA
lowed by an epoch of stage W, the MBM epoch is is 20% of an epoch or greater (> 6 seconds)
scored as having the sleep stage of the epoch that over the frontal regions. Note that the SWA is
follows it. also recorded in the EOG derivations but SEMs
A recent revision of stage N3 rules states that or REMs are not present (Table F3-6;
epochs following an epoch of stage N3 that do Figure F3-11). Chin EMG is variable but typically
not meet criteria for stage N3 are scored as stage less than wakefulness. The amount of stage N3
N2 if there is no intervening arousal and the decreases in adult men but not in women with

TABLE F3-5 Summary of Scoring Rules for Stage N2

Start N2 Continue N2 Stop N2
KC-nonA or SS in first half of EEG with LAMF without KC or SS Transition to stages W, N3, or R
current epoch or last half of the If the epoch (or a group of epochs) is Arousal
previous epoch preceded by an epoch with a Major body movement followed
non-arousal KC or SS by a slow eye movement

KC-nonA, K-complex not associated with arousal; LAMF, low-amplitude mixed-frequency; SS, sleep spindle.

TABLE F3-6 Scoring Rules of Stage N3

N3-A Score stage N3 when 20% or more of an epoch consists of slow wave activity, irrespective of age. (20%
of 30 second epoch ¼ 6 seconds)

EEG: SWA !20% of the epoch (>6 seconds), sleep spindles may be present in stage N3.
EOG: Eye movements are not typically seen during stage N3 sleep.
EMG: In stage N3, chin EMG is of variable amplitude, often lower than in stage N2 sleep and
sometimes as low as in stage R sleep.

EEG, Electroencephalography; EMG, electromyography; EOG, electrooculography.

Note: SWA ¼ EEG activity 0.5 to 2 Hz with peak-to-peak amplitude >75 mv measured over the frontal areas. SWA may
be seen in the EOG derivations.
 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I 25

FIGURE F3-11 n Stage N3 sleep (30-second epoch). The horizontal amplitude grid lines in F4-M1 are 75 microvolts
(mV) apart. The vertical time lines are 1 second apart. Slow wave activity is present for 6 seconds or greater. Note
that slow wave activity is also present in the electromyography (EOG) derivations.

increasing age. This is primarily caused by a for scoring of sleep and associated events: rules, terminology
decrease in the amplitude of slow waves that and technical specifications, ed 1, Westchester, IL, 2007,
American Academy of Sleep Medicine.
occurs in men with aging. Sleep staging based 2. Silber MH, Ancoli-Israel S, Bonnet MH, et al: The visual
on the criteria of the R&K Manual used central scoring of sleep in adults, J Clin Sleep Med 15:121–131,
derivations to detect the amount of stage 3 and 2007.
4 sleep. As slow waves have a greater amplitude 3. Rechtschaffen A, Kales A (eds) A manual of standardized ter-
minology techniques and scoring system for sleep stages of human
in the frontal regions, the amount of stage N3 sleep, Los Angeles, 1968, Brain Information Service/Brain
exceeds the amount of stage 3 and stage 4 using Research Institute, UCLA.
R&K rules with central derivations. 4. Berry RB, Brooks R, Gamaldo CE, et al: for the
American Academy of Sleep Medicine: The AASM
manual for the scoring of sleep and associated events: rules,
REFERENCES terminology and technical specifications, Version 2.0,
1. Iber C, Ancoli-Israel S, Chesson A, Quan SF: for the Darien, IL, 2012, American Academy of Sleep Medicine.
American Academy of Sleep Medicine: The AASM manual www.aasmnet.org, Accessed June 1, 2014.
 PATIENT 3

A 35-Year-Old Woman
Who is Taking Fluoxetine
and a Benzodiazepine
Patient A: Thirty second tracing of stage N2 from a sleep study of a patient with depression and day-
time sleepiness is shown in Figure P3-1. The patient is taking fluoxetine and clonazepam.

FIGURE P3-1 n A 30-second tracing, with magnification of a waveform present in frequent bursts of activity.

QUESTIONS
1. What is the pattern of the eye movements shown in Figure P3-1 called?

2. Why are the bursts of the waveform shown in the blow-up in Figure P3-1 so frequent?

3. Figure P3-2 is a 30-second tracing of the patient undergoing biocalibration. During this procedure,
the patient is asked to open and close the eyes and to look up, down, left, and right. Consider the
first commands. In what order were the commands “eyes open” and “eyes closed” given?

ANSWERS
1. Answer: The eye movement pattern is called Prozac eyes.
Discussion: Such eye movements were first described in patients taking fluoxetine, but the pattern
is common in patients taking any selective serotonin reuptake inhibitor (SSRI). Slow eye movement
may be seen in eyes-closed wakefulness and stage N1 sleep. Normally, eye movements cease during
stage N2 sleep. However, SSRI eyes are often present during stage N2. Of note, the pattern of SSRI
26
PATIENT 3 A 35-YEAR-OLD WOMAN WHO IS TAKING FLUOXETINE AND A BENZODIAZEPINE 27

FIGURE P3-2 n Tracings during biocalibration. The patient performed eye movements at the commands (Look
down, Look up, Look right, Look left) from the sleep technologist.

eyes may be a mixture of slow eye movements (SEMs) and more rapid eye movements (REMs).2,3
SSRI eye movements are not thought to have special significance but may make staging sleep more
challenging (specifically scoring stage N2 and stage R).

2. Answer: Sleep spindle bursts are frequent, which is consistent with the use of clonazepam.
Discussion: Sleep spindle activity is pronounced, which suggests that the patient is taking a benzo-
diazepine receptor agonist (BZRA)4,5 (e.g., a benzodiazepine or non-benzodiazepine hypnotic such as
zolpidem, eszopiclone, or zaleplon). Frequent spindles in patients taking BZRAs are sometimes called
drug spindles. They tend to be faster, but in this patient, spindle activity is 12 to 13 Hz. Recall that sleep
spindles may range from 11 to 16 Hz. How many sleep spindle bursts per epoch is abnormal? In gen-
eral, the number of sleep spindle bursts per epoch decreases with age. For patients of age greater than
20 years, more than 4 to 5 sleep spindles bursts per epoch suggests the possibility of a BZRA med-
ication effect. Benzodiazepines increase sleep spindle activity and decrease the amplitude of slow
waves and therefore tend to reduce the amount of stage N3. The non-benzodiazepine BZRAs also
increase sleep spindles bursts but have much less effect of slow wave amplitude. Hence they do not
reduce the amount of stage N3. In this patient, the benzodiazepine clonazepam is causing the frequent
bursts of sleep spindles. Clonazepam is a benzodiazepine with a long duration of action that is used for
its antianxiety activity. Although not approved by the U.S. Food and Drug Administration (FDA) as a
hypnotic, it is often used for this indication in patients with both anxiety and insomnia.

3. Answer: “Eyes open,” “eyes closed”

Discussion: When the eyes are closed, the globe is turned upward (Bell phenomenon). With eye
opening, the globe turns downward. As the cornea is positive, this makes E1 more positive and E2
more negative, which results in a downward deflection in E1-M2 and an upward deflection in
E2-M2. For eye closure, the globe turns upward, and the deflections in E1 and E2 are the opposite.
Deflections in the frontal derivations may also be seen and are parallel to changes in E2-M2, as E2,
F3, and F4 are located above the eyes. Note the upward deflection in F4-M1 with eye opening in
parallel with E2-M2. For lateral eye movements, remember that the rightward movement makes E2
more positive (downward deflection) and E1 more negative (upward deflection). As F4 is on the
right side, deflections with lateral movements are similar to E2 and for F3 similar to E1. In
Figure P3-1, note the upward deflection in E2-M2 and F4-M1 with eye opening and the downward
deflection in E-M1 and F4-M1 with lateral eye movement to the right.
28 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I

CLINICAL PEARLS
1. It is important to review a patient’s history for drugs that may affect the PSG waveforms, sleep architecture,
or both.
2. Patients taking SSRIs may have persistent eye movements in stage N2. Normally, eye movements have
ceased with transition to stage N2. Recall that SEMs may be seen both in stage W and stage N1.
3. BZRAs may increase the frequency of sleep spindle bursts per epoch.
4. Eye opening is associated with a downward deflection of the globe and eye closure with an upward deflec-
tion (Bell phenomenon). F4-M1 has upward deflections with eye opening and downward with eye closure.
Deflections in F4-M1 parallel deflections in E2-M2 as both electrodes are above the eyes on the right side of
the body.

REFERENCES
1. Berry RB, Brooks R, Gamaldo CE, et al: for the American Academy of Sleep Medicine: The AASM manual for the scoring of sleep
and associated events: rules, terminology and technical specifications, Version 2.0, Darien, IL, 2012, American Academy of Sleep
Medicine. www.aasmnet.org, Accessed June 1, 2014.
2. Schenck CH, Mahowlad MW, Kim SW, et al: Prominent eye movements during NREM sleep and REM sleep behavior
disorder associated with fluoxetine treatment of obsessive-compulsive disorder, Sleep 15:226–235, 1992.
3. Armitage R, Trivedi M, Rush AJ: Fluoxetine and oculomotor activity during sleep in depressed patients, Neuropsychopharma-
cology 12:159–165, 1995.
4. Nicolas A, Petit D, Rompré S, Montplaisir J: Sleep spindle characteristics in healthy subjects of different age groups,
Clin Neurophysiol 112:521–527, 2001.
5. Johnson LC, Spinweber CL, Seidel WF, et al: Sleep spindle and delta changes during chronic use of a short acting and a long
acting benzodiazepine hypnotic, Electroencephalogr Clin Neurophysiol 55:662–667, 1983.
6. Libenson MH: Practical approach to electroencephalography, Philadelphia, 2010, Saunders pp. 27–20, 126–129.
7. Berry RB: Fundamentals of sleep medicine, Philadelphia, 2012, Saunders, pp. 48–52.

PATIENT 4

Scoring Stage N1 versus Stage W

in Two Patients
Patient A: A 30-second epoch soon after lights out is shown in Figure P4-1.

FIGURE P4-1 n A 30-second epoch soon after the start of the sleep study.
28 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I

CLINICAL PEARLS
1. It is important to review a patient’s history for drugs that may affect the PSG waveforms, sleep architecture,
or both.
2. Patients taking SSRIs may have persistent eye movements in stage N2. Normally, eye movements have
ceased with transition to stage N2. Recall that SEMs may be seen both in stage W and stage N1.
3. BZRAs may increase the frequency of sleep spindle bursts per epoch.
4. Eye opening is associated with a downward deflection of the globe and eye closure with an upward deflec-
tion (Bell phenomenon). F4-M1 has upward deflections with eye opening and downward with eye closure.
Deflections in F4-M1 parallel deflections in E2-M2 as both electrodes are above the eyes on the right side of
the body.

REFERENCES
1. Berry RB, Brooks R, Gamaldo CE, et al: for the American Academy of Sleep Medicine: The AASM manual for the scoring of sleep
and associated events: rules, terminology and technical specifications, Version 2.0, Darien, IL, 2012, American Academy of Sleep
Medicine. www.aasmnet.org, Accessed June 1, 2014.
2. Schenck CH, Mahowlad MW, Kim SW, et al: Prominent eye movements during NREM sleep and REM sleep behavior
disorder associated with fluoxetine treatment of obsessive-compulsive disorder, Sleep 15:226–235, 1992.
3. Armitage R, Trivedi M, Rush AJ: Fluoxetine and oculomotor activity during sleep in depressed patients, Neuropsychopharma-
cology 12:159–165, 1995.
4. Nicolas A, Petit D, Rompré S, Montplaisir J: Sleep spindle characteristics in healthy subjects of different age groups,
Clin Neurophysiol 112:521–527, 2001.
5. Johnson LC, Spinweber CL, Seidel WF, et al: Sleep spindle and delta changes during chronic use of a short acting and a long
acting benzodiazepine hypnotic, Electroencephalogr Clin Neurophysiol 55:662–667, 1983.
6. Libenson MH: Practical approach to electroencephalography, Philadelphia, 2010, Saunders pp. 27–20, 126–129.
7. Berry RB: Fundamentals of sleep medicine, Philadelphia, 2012, Saunders, pp. 48–52.

PATIENT 4

Scoring Stage N1 versus Stage W

in Two Patients
Patient A: A 30-second epoch soon after lights out is shown in Figure P4-1.

FIGURE P4-1 n A 30-second epoch soon after the start of the sleep study.
 PATIENT 4 SCORING STAGE N1 VERSUS STAGE W IN TWO PATIENTS 29

Patient B: A 30-second epoch in a patient who does not generate alpha rhythm with eye closure is
shown in Figure P4-2. Assume the previous epoch is stage W.

FIGURE P4-2 n A 30-second epoch following an epoch of stage W. This patient does not generate alpha rhythm with
eye closure.

QUESTIONS
1. What sleep stage is shown in Figure P4-1?

2. What sleep stage is shown in Figure P4-2?

ANSWERS
1. Answer: Stage N1
Discussion: Alpha rhythm is present in the first third of the epoch (A) but is attenuated for the
majority of the epoch and replaced by low amplitude mixed frequency activity. No sleep spindles
or K-complexes are present. Thus, the epoch meets criteria for stage N1. The EEG of stage N1 is
low-amplitude mixed-frequency (LAMF) with predominant activity in the 4 to 8 Hz range. Stage
N1 may contain slow eye movements (SEMs). Vertex sharp waves often occur at the transition to
stage N2.

2. Answer: Stage N1
Discussion: In individuals who do not generate alpha rhythm with eye closure, the occipital elec-
troencephalography (EEG) stage W with eyes open and eyes closed, appear much the same. The
EEG shows low amplitude activity with a mixture of alpha and beta frequencies without the rhyth-
micity of alpha rhythm. Electrooculographic derivations may show REMs, blinks, or reading eye
movements. Chin electromyography (EMG) tone is variable but usually higher than during sleep.
In individuals who do not generate alpha rhythm with eye closure, the AASM Scoring Manual1,2
states that stage W should be scored if the majority of the epoch contains any of the following: rapid
eye movements (REMs) with normal or high muscle tone, eye blinks, or reading eye movements.
The requirement of normal or high muscle tone with REMs is to differentiate stage W with REMs
from stage R (low muscle tone). The AASM Scoring Manual states that stage N1 should be scored in
patients who do not generate alpha rhythm at the earliest occurrence of SEMs, vertex sharp waves,
or the presence of LAMF activity with a slowing of the EEG by 1 Hz or greater compared with
stage W. The AASM Scoring Manual does not directly address the position in the epoch where
SEMs, vertex sharp waves, or slowing of the EEG first occur. However, by convention, the
sleep stage occupying the majority of the epoch names the epoch. If these phenomenon occur in
the first half of the epoch then stage N1 is scored (unless there is evidence for another sleep stage).
In Figure P4-2, SEMs are noted in the first half of the epoch, so stage N1 is scored. If the first
30 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I

FIGURE P4-3 n A 30-second epoch following an epoch of stage W in a patient who does not generate alpha rhythm
with eye closure. This is stage N1 as the slow eye movements appear in the first half of the epoch. A vertex sharp
wave is noted at A.

evidence of stage N1 was in the last half of the epoch, then the current epoch would be stage W and
the next epoch stage N1. This assumes that no evidence for another sleep stage (e.g., stage N2)
exists in the following epoch.
In Figure P4-3, another example of an epoch at sleep onset in a patient who does not generate
alpha activity is shown. The first part of the epoch has REMs associated with higher EMG tone than
is present for the rest of the epoch (consistent with stage W). However, the chin EMG falls during
the first half of the epoch, REMs cease, the EEG slows, and slow eye movements are noted. As the
slow eye movements and EEG slowing begin in the first half of the epoch, the majority of the epoch
meets criteria for stage N1. Therefore, the epoch is scored as stage N1. A vertex sharp wave is also
seen in the last half of the epoch (A).

CLINICAL PEARLS
1. The scoring rules for stage W and N1 are different for patients who do not generate alpha rhythm with eye
closure.
2. In individuals who do not generate alpha rhythm with eye closure, stage W is scored if REMs with normal or
high muscle tone, eye blinks, or reading eye movements are present for the majority of the epoch.
3. In patients who do not generate alpha rhythm with eye closure, stage N1 is scored at the earliest occurrence
of any of the following phenomenon: SEMs, vertex sharp waves, or the presence of LAMF EEG activity with a
slowing of the frequency by 1 Hz or greater compared with stage W.

REFERENCES
1. Iber C, Ancoli-Israel S, Chesson A, Quan SF, for the American Academy of Sleep Medicine: The AASM manual for scoring of
sleep and associated events: rules, terminology and technical specifications, ed 1, Westchester, IL, 2007, American Academy of Sleep
Medicine.
2. Berry RB, Brooks R, Gamaldo CE, et al: for the American Academy of Sleep Medicine: The AASM manual for the scoring of sleep and
associated events: rules, terminology, and technical specifications, Version 2.0, Darien, IL, 2012, American Academy of Sleep Med-
icine, www.aasmnet.org, Accessed June 1, 2014.
 PATIENT 5

Recognizing Stages N1 and N2

QUESTIONS
1. What is the sleep stage in Figure P5-1? Assume the previous epoch was stage N1.

1sec

1sec

FIGURE P5-1 n A 30-second tracing. Assume the previous epoch was stage N1.

2. What sleep stage is shown in Figure P5-2?

1sec

1sec

FIGURE P5-2 n A 30-second tracing with a blow up of waveform activity.

31
32 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I

3. Figures P5-3 and P5-4 are two consecutive epochs. What sleep stage are these epochs?

FIGURE P5-3 n A 30-second tracing. Figure P5-4 is the next epoch.

1sec

FIGURE P5-4 n A 30-second tracing of the epoch following the one in Figure P5-3.

ANSWERS
1. Answer: Stage N1
Discussion: The K-complex (KC) in the first part of the figure is associated with an arousal (note
alpha activity) and therefore the epoch should not be scored as stage N2. A KC not associated with an
arousal is present in the second half of the epoch. The next epoch would be scored as stage N2 if
electroencephalography (EEG) continued to demonstrate low-amplitude mixed-frequency (LAMF)
activity even if another KC or sleep spindle was not present in that epoch. Although the arousal
occupies a considerable amount of the time, majority of the epoch in Figure P5-1 was sleep. Arousal
scoring is discussed in Fundamentals 5. Score an arousal during sleep stages N1, N2, and N3 if an
abrupt shift of EEG frequency, including alpha, theta, and frequencies greater than 16 Hz (but not
spindles), lasts at least 3 seconds, with at least 10 seconds of stable sleep preceding the change. Scoring of
an arousal during stage R requires a concurrent increase in the submental (chin) electromyography
(EMG) tone, lasting at least 1 second.1–3 KCs may be associated with sleep spindles. Therefore, it is
important to avoid incorrectly identifying a KC associated with sleep spindles as a KC associated with
an arousal. If necessary, go to a 10-second window, and count oscillations to determine the wave form
frequency. In Figure P5-1, a blow-up shows the frequency to be 8 to 9 hertz (Hz).

2. Answer: Stage N2
Discussion: Sleep spindles are noted in the first half of the epoch, and not enough slow wave
activity is present to score stage N3. The sleep spindle shown in the blow-up has a frequency of 14 Hz.

3. Answer: Both epochs are stage N2

Discussion: The first epoch has a KC (not associated with an arousal) in the first half and is stage
N2. The second epoch does not have KCs or sleep spindles but is still stage N2, according to the
stage N2 continuation rule. Epochs with LAMF EEG activity without KCs or sleep spindles are
 PATIENT 6 STAGE N3 IN A NORMAL INDIVIDUAL AND A PATIENT WITH CHRONIC PAIN 33

scored as stage N2 if they follow epochs with sleep spindles of KCs. This assumes that there is no
intervening arousal or intervening major body movements followed by slow eye movements.

CLINICAL PEARLS
1. A K complex (KC) associated with an arousal does not indicate the presence of stage N2 sleep. The KC
arousal event affects sleep staging in the same way as an arousal without a KC. It is important not to confuse
a KC associated with spindles with a KC arousal.
2. Epochs following an epoch of definite stage N2 (one or more KCs or sleep spindles in first half of the epoch or
last half of previous epoch) continue to be scored as stage N2, even if the epochs in question do not contain
KCs or sleep spindles. This assumes that no intervening arousal or a transition to stage W, stage N3, or stage
R exists.

REFERENCES
1. Iber C, Ancoli-Israel S, Chesson A, Quan SF: for the American Academy of Sleep Medicine: The AASM manual for scoring of
sleep and associated events: rules, terminology and technical specifications, ed 1, Westchester, IL, 2007, American Academy of Sleep
Medicine.
2. Silber MH, Ancoli-Israel S, Bonnet MH, et al: The Visual scoring of sleep in adults, J Clin Sleep Med 15:121–131, 2007.
3. Berry RB, Brooks R, Gamaldo CE, et al., for the American Academy of Sleep Medicine: The AASM manual for the scoring of
sleep and associated events: rules, terminology and technical specifications, Version 2.0, Darien, IL, 2012, American Academy of Sleep
Medicine. www.aasmnet.org, Accessed June 1, 2014.

PATIENT 6

Recognizing Stage N3 in a Normal

Individual and a Patient with
Chronic Pain
QUESTIONS
1. What sleep stage is shown in the 30-second tracing in Figure P6-1? Amplitude gridlines of +37.5
and !37.5 microvolts (mV) are shown for derivation F4-M1.

FIGURE P6-1 n A 30-second epoch with amplitude grid lines in F4-M1.

 PATIENT 6 STAGE N3 IN A NORMAL INDIVIDUAL AND A PATIENT WITH CHRONIC PAIN 33

scored as stage N2 if they follow epochs with sleep spindles of KCs. This assumes that there is no
intervening arousal or intervening major body movements followed by slow eye movements.

CLINICAL PEARLS
1. A K complex (KC) associated with an arousal does not indicate the presence of stage N2 sleep. The KC
arousal event affects sleep staging in the same way as an arousal without a KC. It is important not to confuse
a KC associated with spindles with a KC arousal.
2. Epochs following an epoch of definite stage N2 (one or more KCs or sleep spindles in first half of the epoch or
last half of previous epoch) continue to be scored as stage N2, even if the epochs in question do not contain
KCs or sleep spindles. This assumes that no intervening arousal or a transition to stage W, stage N3, or stage
R exists.

REFERENCES
1. Iber C, Ancoli-Israel S, Chesson A, Quan SF: for the American Academy of Sleep Medicine: The AASM manual for scoring of
sleep and associated events: rules, terminology and technical specifications, ed 1, Westchester, IL, 2007, American Academy of Sleep
Medicine.
2. Silber MH, Ancoli-Israel S, Bonnet MH, et al: The Visual scoring of sleep in adults, J Clin Sleep Med 15:121–131, 2007.
3. Berry RB, Brooks R, Gamaldo CE, et al., for the American Academy of Sleep Medicine: The AASM manual for the scoring of
sleep and associated events: rules, terminology and technical specifications, Version 2.0, Darien, IL, 2012, American Academy of Sleep
Medicine. www.aasmnet.org, Accessed June 1, 2014.

PATIENT 6

Recognizing Stage N3 in a Normal

Individual and a Patient with
Chronic Pain
QUESTIONS
1. What sleep stage is shown in the 30-second tracing in Figure P6-1? Amplitude gridlines of +37.5
and !37.5 microvolts (mV) are shown for derivation F4-M1.

FIGURE P6-1 n A 30-second epoch with amplitude grid lines in F4-M1.

34 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I

2. What is the sleep stage shown in Figure P6-2 with a blow-up in Figure P6-3? What is the name of
this particular pattern of this sleep stage? Assume the second 15 seconds has the same characteristics
as the 15 seconds shown.

FIGURE P6-2 n A 15-second

tracing.

FIGURE P6-3 n A 6-second tracing (as seen in a

10-second window) of Figure P6-2.

ANSWERS
1. Answer: Stage N3
Discussion: Just enough slow wave activity (SWA) is present to meet the criteria for stage N3—
about 8 seconds (! 6 seconds required) (Figure P6-4). The dark bars at the top of Figure P6-4 indi-
cate portions meeting the criteria for SWA (0.5 to 2 hertz [Hz] with > 75 mV peak-to-peak ampli-
tude of the electroencephalography (EEG) frequency in F4-M1). It is sometimes difficult to see the
background of 0.5 to 2 Hz and to determine if amplitude criteria are met. In Figure P6-5, a sche-
matic shows the appearance of waves with frequencies of 0.5, 1, and 2 Hz.

2: Answer: Studies have shown that for epochs on the borderline between stage N2 and N3 that
scorer agreement is often as low as 50%.1 Stage N3, as slow wave activity is present for the entire
epoch. The patient has alpha–delta sleep. Alpha waves are superimposed on the slow waves.
 PATIENT 6 STAGE N3 IN A NORMAL INDIVIDUAL AND A PATIENT WITH CHRONIC PAIN 35

FIGURE P6-4 n Stage N3 with slow wave activity (SWA) shown by dark horizontal bars on the top of the tracing.
Amplitude grid lines of "37.5 and + 37.5 mV allow one to determine if amplitude criteria are met.

1
FIGURE P6-5 n Illustration of the frequency range 0.5 to 2 hertz (Hz) used to determine slow sec
wave activity.

Discussion: The finding of prominent alpha activity (8–13 Hz) during non–rapid eye movement
(NREM) sleep is often called alpha anomaly, alpha sleep, alpha intrusion, or alpha–delta sleep (if noted
in association with stage N3). Prominent alpha activity makes sleep staging more challenging.
Of interest, the alpha activity may be more prominent in the frontal regions than in the occipital
regions in contrast to the typical alpha rhythm. When viewing a tracing of alpha–delta sleep in
a 30-second window (see Figure P6-2), a background of diffuse higher-frequency activity is felt
to be superimposed on the slow waves. By switching to a 10-second window (see Figure P6-3),
the smaller wave forms that are superimposed on slower activity (alpha 8–13 Hz) can be
counted in 1 second.
First described in 1973 by Hauri and Hawkings,2 alpha–delta sleep was once thought to be a
characteristic finding associated with fibromyalgia (FM).3 However, alpha sleep is not seen in
all patients with FM and may occur in patients with psychiatric and chronic pain disorders.
Mahowald and Mahowald4 concluded that alpha sleep was not specific for FM and was not neces-
sarily associated with symptoms of myalgia. It was present in 15% of normal subjects in
undisturbed sleep.
Roizenblatt and coworkers5 also studied patients with FM who were off medications and normal
controls. Alpha rhythm was noted during sleep in 70% of patients with FM and 16% of normal
individuals. Three distinct patterns were noted: (1) phasic alpha patterns—episodic alpha occurring
simultaneously with delta activity (70% FM, 7% controls); (2) tonic alpha continuously present
throughout NREM sleep (20% of FM and 9% of controls); and (3) low alpha pattern seen in
30% of FM patients and 84% of controls. The phasic pattern was associated with lower sleep effi-
ciency, decreased slow wave sleep, longer morning pain, and subjective feeling of superficial sleep.
Further research is needed to confirm these findings.
36 FUNDAMENTALS 3 SLEEP STAGING IN ADULTS I

CLINICAL PEARLS
1. To determine slow wave activity, place amplitude grid lines "37.5 + 37.5 mV to identify slow activity with
greater than 75 mV peak-to-peak activity in F4-M1 (or F3-M2).
2. If a fast frequency appears to be superimposed on slow waves, switch to a 10-second window to determine if
fast activity is in the alpha range. This may help identify alpha–delta sleep.
3. Alpha sleep is nonspecific but is present in many patients with psychiatric disorders and chronic pain
syndromes. It may be a normal variant. One study suggests that when alpha activity is restricted to stage
N3 sleep (versus all stages of sleep), it may be more specific for disorders associated with chronic pain. How-
ever, the pattern may still be a normal variant.

REFERENCES
1. Rosenberg RS, Van Hout S: The American Academy of Sleep Medicine inter-scorer reliability program: sleep stage scoring,
J Clin Sleep Med 9:81–87, 2013.
2. Hauri P, Hawkins DR: Alpha-delta sleep, Electroenceph Clin Neurophysiol 34:233–237, 1973.
3. Moldofsky H, Scarisbrick P, England R, Smythe H: Musculoskeletal symptoms and non-REM sleep disturbance in patients
with “fibrositis syndrome” and healthy subjects, Psychosom Med 37:341–351, 1975.
4. Mahowald ML, Mahowald MW: Nighttime sleep and daytime functioning (sleepiness and fatigue) in less well defined chronic
rheumatic disease with particular reference to “alpha-delta NREM sleep anomaly,” Sleep Med 1:195–207, 2000.
5. Roizenblatt S, Moldofsky H, Benedito-Silva AA, Tufik S: Alpha sleep characteristics in fibromyalgia, Arthritis Rheum
44:222–230, 2001.
 FUNDAMENTALS 4

Scoring Stage R

The electroencephalographic (EEG) activity in regions. TMA is characterized by short irregular

stage R resembles that of stage N1 and gener- bursts of EMG activity (<0.25 seconds) in the
ally contains low-amplitude mixed-frequency chin derivations superimposed on low chin activ-
(LAMF) activity (frequencies 4 to 7 hertz ity. TMA may also occur in leg derivations often
[Hz]). However, alpha activity in also commonly associated with bursts of REMs.
present in stage R and usually has a frequency 1 The three components of stage R include (1)
to 2 Hz lower than during wakefulness.1–4 LAMF EEG without K-complexes (KCs) or
Because rapid eye movements (REMs) may sleep spindles, (2) rapid eye movements (REMs),
occur during eyes-open wakefulness, the pres- and (3) low chin EMG tone (Figure F4-1). An
ence of low chin electromyographic (EMG) tone epoch containing all three characteristics of
is essential for identification of stage R (versus stage R is referred to as definite or unambiguous
stage W with REMs). In the AASM Scoring Man- stage R.
ual,1–4 low chin EMG tone is defined as baseline The three components of stage R may not all
EMG activity in the chin derivation no higher start and stop at the same time. In addition, REMs
than in any other sleep stage and usually at the are episodic, and not all epochs of stage R contain
lowest level of the entire night. REMs. Therefore, special rules are needed for
Sawtooth waves in the EEG (see Fundamen- the start, continuation, and end of stage R as well
tals 2) and brief transient muscle activity (TMA) as transitions from other sleep stages to REM
in the chin EMG (see Patient 9) are often present sleep. During periods of REM sleep early in the
during stage R but are not part of the criteria for night, segments of sleep may have a mixture of
scoring stage R. However, the presence of saw- KCs or sleep spindles and REMs. Rules for scor-
tooth waves or TMA is supportive that stage R ing segments of the record with a mixture of
is present. Sawtooth waves are characterized by REMs, low chin muscle tone, and KCs, or sleep
triangular waves with serrated edges and a fre- spindles, or a combination of all of these; these
quency of 2 to 6 Hz maximal over central are also discussed in this chapter.

FIGURE F4-1 n An epoch of definite rapid eye movement (REM) sleep with REMs, low chin electromyography (EMG)
tone, and an electroencephalography (EEG) with low amplitude mixed frequency activity without K- complexes or
sleep spindles. Sawtooth waves (C4-M1) and a burst of alpha activity (O2-M1) are also present in this epoch and are
often present during stage R. However sawtooth waves are not required for scoring stage R. Alpha activity during
stage R is often 1 to 2 Hz lower in frequency than the alpha activity during stage W.

37
38 FUNDAMENTALS 4 SCORING STAGE R

RULES FOR SCORING STAGE R START OF STAGE R

Rules for scoring stage R are displayed in Segments of sleep that precede and are contiguous
Tables F4-1, F4-2, and F4-3 (adapted from the with an epoch of definite stage R (REM rule 1,
AASM Scoring Manual1–4). Table F4-1) are scored as stage R if the EEG
shows LAMF activity without KCs or sleep
spindles, the chin EMG activity is at the REM
DEFINITE STAGE R level, and no intervening arousal occurs (REM
rule 2, Table F4-1). The segments of sleep must
Score stage R sleep (definite stage R) in epochs also not contain slow eye movements (SEMs)
with ALL of the following phenomena (REM that follow an arousal or stage W. SEMs may
rule 1, Table F4-1): sometimes be seen in stage R (usually mixed
a. LAMF EEG activity without KCs or sleep with REMs). However, SEMs following an
spindles arousal or stage W are evidence for a transition
b. Low chin EMG tone for the majority of to stage N1.
the epoch and concurrent with REMs If the majority of an epoch meets all the above
c. REMs at any position within the epoch criteria (REM rules 2a to 2d, Table F4-1), the
An example of an epoch of definite stage R is epoch is scored as stage R. If a conflict with a stage
shown in Figure F4-1. N2 rule exists, REM rules take precedence.

TABLE F4-1 Stage R Rules: Part 1

1. Score stage R sleep in epochs with ALL of the following phenomena (definite stage R):
a. Low-amplitude, mixed-frequency (LAMF) EEG activity without K-complexes or sleep spindles
b. Low chin EMG tone for the majority of the epoch and concurrent with REMs
c. Rapid eye movements (REMs) at any position within the epoch
2. Begin scoring stage R according to the following rule: Score segments of sleep preceding and contiguous
with an epoch of definite stage R in the absence of rapid eye movements, as stage R IF all of the following are
present:
a. The EEG shows LAMF activity without K-complexes or sleep spindles
b. The chin EMG tone is low (at the stage R level)
c. No intervening arousal is present
d. Slow eye movements following an arousal or stage W are absent
If the majority of an epoch meets all the criteria (2a to 2d), the epoch is scored as stage R. If there is a conflict
with a stage N2 rule, REM rules takes precedence.
3. Continue to score segments of sleep that follow one or more epochs of definite stage R as defined in rule 1, in
the absence of rapid eye movements, as stage R if ALL of the following are present:
a. The EEG shows LAMF EEG activity without K-complexes or sleep spindles
b. The chin EMG tone is low (at the stage R level) for the majority of the epoch
c. There is no intervening arousal
If the majority of an epoch meets these criteria, the epoch is scored as stage R.

Adapted from references 1 and 4.

EEG, Electroencephalography; EMG, electromyography.

TABLE F4-2 REM Rules: Part 2

4. End scoring stage R sleep when ONE OR MORE of the following occur:
a. Transition to stage W or N3 has occurred.
b. An increase in chin electromyography (EMG) tone above the level of stage R is seen for the majority of the
epoch and criteria for stage N1 are met.
c. Arousal occurs and is followed by low-amplitude, mixed-frequency (LAMF) electroencephalography (EEG)
and the EMG tone remains low. If slow eye movements (SEMs) follow the arousal, score the segment
containing them as stage N1, and continue to score stage N1 until evidence for another stage of sleep is
present. If no SEMs follow the arousal and chin EMG tone remains low, continue to score as stage R.
d. A major body movement followed by SEMs and LAMF EEG without K-complexes (KCs) or sleep spindles (SS),
score stage N1 until evidence for another sleep stage. (If no SEMs are present, and chin tone remains low,
continue to score stage R).*
e. One or more K complexes or sleep spindles are present in the first half of the epoch in the absence of rapid
eye movements,
even if chin EMG tone remains low. (Score the epoch as stage N2.)

Adapted from references 1 and 4.

*Score epoch containing major body movement (MBM) by MBM rules (see Fundamentals 5).
Exploring the Variety of Random
Documents with Different Content
 Oil, Croton. Syn. Crotonis oleum (B. P.), Oleum crotonis (Ph. E.), O. tiglii (Ph.
L.), L. From the shelled seeds of Croton tiglium or Molucca grains. Imported
chiefly from the East Indies. It is one of the most powerful cathartics known, and
acts when either swallowed or merely placed in the mouth. Externally, it is a
rubefacient and counter-irritant, often causing a crop of painful pustules, like
tartar emetic.—Dose, 1 to 2 drops, on sugar; in apoplexy, &c. It is poisonous in
larger doses. Sp. gr. ·947 to ·953. Prod. Unshelled seeds, 22% to 25%; shelled
do., 32% to 35%.
Pure croton oil is soluble in an equal volume of alcohol of ·796, but in 2 or 3
days about 96% of the oil separates. In France the marc is exhausted with
alcohol, and the oil thus obtained is added to that previously obtained from the
same seeds by expression. The East Indian oil (OLEUM CROTONIS EXOTICUM) is
usually of a pale yellow; that pressed in England (o. crotonis Anglicanum) is much
darker.
Oil of Cu′cumber. Syn. Oleum cucurbitæ, L. From the seeds of Cucurbita
pepo or squash, and the C. melopepo or pumpkin. Pale; used in lamps; and,
sometimes, as a soothing application to piles. Sp. gr. ·9231. Prod. 24%.
Oil of Eggs. Syn. Oleum ovi, O. o. vitelli, O. ovorum, L. From the yolks of
eggs, gently heated until they coagulate and the moisture has evaporated, and
then pressed or broken up, digested in boiling rectified spirit, the tincture filtered
whilst hot, and the spirit distilled off. Bland; emollient. The common plan is to fry
the yolks hard; but the oil is then darker coloured and stronger. The P. Cod.
orders them to be exhausted with ether, by displacement. Formerly commonly
used to ‘kill’ quicksilver, and still held in great esteem in some parts of England for
sore nipples and excoriations. Prod. 10 to 12 eggs yield 1 oz. See Mixed oils.
Oil of Garden Cress. Syn. Oleum lepidii sativi, L. From the seed. Drying. Sp.
gr. ·9240. Prod. 54%.
Oil of Gar′den Spurge. Syn. Oleum lathyris, O. euphorbiæ l., L. From the
seeds of Euphorbia lathyris or garden spurge. Cathartic.—Dose, 3 to 8 drops. Sp.
gr. ·9281. Prod. 30% to 41%. Croton oil mixed with 6 times its weight of nut or
rape oil is usually sold for it.
Oil of Gingel′ly. Syn. Oil of Sesamum, Benne oil, Teel o., Tel o.; Oleum sesami,
L. From the seeds of Sesamum orientale (Willd.), or gingelly. Pale; bland. Used in
salads, paints, &c.; also to adulterate oil of almonds. Prod. 46%.
Oil, Gourd. See Oil of Cucumber.
Oil of Ground Nuts. From the nuts of Arachis hypogæa. Glutinous.
Oil of Gurgun. See Balsam, Gurgun.
 Oil of Hemp. Syn. Oleum cannabis, L. From the seed of Cannabis sativa
(Linn.), or common hemp. Mawkish. Sometimes used for frying, but chiefly for
paints, soaps, &c. Freely soluble in boiling alcohol; does not thicken until cooled
to 5° Fahr. Sp. gr. ·9276. Prod. 18% to 24%.
Oil of Jatro′pha. Syn. Oil of wild castor seeds; Oleum jatrophæ, L. From the
seeds of Jatropha purgans. Somewhat resembles CROTON OIL. Used for lamps in
the East Indies.
Oil, Kundah. Syn. Tallicoonah o.; Oleum touloucounæ, L. From the fruit of
Carapa Touloucouna. Rancid, nauseous, vermifuge, rubefacient, emetic, and
purgative. Chiefly used in lamps.
Oil, Lard. Syn. Tallow o., Crude olein, C. oleic acid; Oleum adipis, L. By
separating the olein of lard from the stearin by means of boiling alcohol. Only
applicable where spirit is cheap. The product is, however, excellent. The crude
oleic acid, or lard oil of commerce, is chiefly obtained as a secondary product in
the manufacture of stearin. It is purified by agitation with sulphuric acid, and
subsequently by steaming it, or washing it with hot water. Burns well in lamps, if
the wick-tube is kept cool. Sp. gr. ·9003.
Oil, Linseed. Syn. Oleum lini (B. P., Ph. L., E. & D.), L. 1. (Cold-drawn linseed
oil; Oleum lini sine igne.) From the seed of Linum usitatissimum (Linn.), or common
flax, bruised or crushed, and then ground and expressed without heat. Pale,
insipid, viscous; does not keep so well as the next. Prod. 17% to 20%.
2. As the last, but employing a steam heat of about 200° Fahr. Amber
coloured; less viscous than the last; congeals at 2°; soluble in 5 parts of boiling
and 40 parts of cold alcohol. Both are drying and cathartic.—Dose, 1 to 2 oz.; in
piles, &c. Chiefly used in paints, varnishes, &c. Sp. gr. ·9347. Prod. 22% to 27%.
3. (Boiled linseed oil.) See Oils (Drying).
Oil of Mace (Expressed). See Oil of Nutmeg (Expressed).
Oil of Male Fern. See Extract of Male fern.

Oil of Mustard. Syn. Oleum sinapis, L. 1. (Oil of white mustard.) From Sinapis
alba, or white mustard, but chiefly from Sinapis arvensis, S. chinensis, S.
dichotoma, S. glauca, S. ramosa, and S. tori. Sweet. Used for the table. Sp. gr.
·9142 (·2160—Ure). Prod. 36%.
2. (Oil of Black mustard; Oleum sinapis nigri, L.) From the ‘hulls’ of black-
mustard seed. Viscid, stimulant. Used in rheumatism, Sp. gr. ·9168 to ·9170. See
Oils (Volatile).
 3. (Oil of White mustard; Oleum raphani, L.) From the seed of Raphanus
raphanistrum (Linn.), or jointed charlock or wild mustard. Prod. 30%.
Oil, Neat’s-foot. Syn. Nerve oil, Trotter o.; Oleum bubulum, O. nervinum,
Axungia pedum tauri, L. From neat’s-feet and tripe, by boiling them in water, and
skimming off the oil. Does not thicken by age. Used to soften leather, to clean
fire-arms, and for other purposes.
Oil, Nut. Syn. Hazel-nut o.; Oleum nucis, O. coryli, L. From the kernels of
Corylus Avellana (Linn.), or hazel-nut tree. Pale, mild tasted, drying; superior to
linseed oil for paints and varnishes. It is commonly sold for oil of almonds and oil
of ben, and is extensively employed to adulterate both. Walnut oil is also
frequently sold for nut oil. Sp. gr. ·9260. Prod. 63%(Ure).
Oil of Nut′meg (Expressed). Syn. Expressed oil of mace, Butter of m.; Oleum
myristicæ (CONCRETUM) (Ph. L.), Myristicæ adeps (Ph. E.), M. butyrum, O. myristicæ
expressum (B. P.), O. moschatæ, O. nucistæ, L. “The concrete oil expressed from the
seed of Myristica officinalis,” Linn. (Ph. L.), or common nutmeg. The nutmegs are
beaten to a paste, enclosed in a bag, exposed to the vapour of hot water, and
then pressed between heated iron plates. Orange coloured, fragrant, spicy;
butyraceous, or solid. It is a mixture of the fixed and volatile oils of the nutmeg.
When discoloured and hardened by age, it is called ‘Banda soap’ (Ol. macis in
massis). When pure, it is soluble in 4 parts of boiling alcohol and in 2 parts of
ether. It has been used in rheumatism and palsy, but is now chiefly employed for
its odour and aromatic qualities. From the East Indies. Prod. 17% to 20%.
Oil, Ol′ive. Syn. Salad oil, Sweet o.; Olivæ oleum (B. P.), Oleum olivarum, O.
olivæ (Ph. L., E., & D.), L. The “oil expressed from the fruit” of “Olea europœa,
Linn.” (Ph. L.), or common olive. Five different methods are employed to obtain
the oil, from the fruit:
1. (Virgin oil; O. o. virgineum, L.); (Huile vierge, Fr.) From olives, carefully
garbled, either spontaneously or only by slight pressure, in the cold. That yielded
by the pericarp of the fruit is the finest.
2. (Ordinary ‘FINE OIL,’) This is obtained by either pressing the olives,
previously crushed and mixed with boiling water, or by pressing, at a gentle heat,
the olives from which the virgin oil has been obtained. The above processes
furnish the finer salad oils of commerce. The cake which is left is called ‘GRIGNON,’
3. (Second quality.) By allowing the bruised fruit to ferment before pressing it.
Yellow; darker than the preceding; but mild and sweet tasted. Much used for the
table.
 4. (‘Gorgon.’) By fermenting and boiling the pressed cake or marc in water,
and skimming off the oil. Inferior.
5. (Oil of the infernal regions; Oleum omphacinum) is a very inferior quality of oil,
which is skimmed off the surface of the water in the reservoirs into which the
waste water which has been used in the above operations is received, and
allowed to settle. The last two are chiefly used for lamps, and in soap-making, &c.
Of the principal varieties of olive oil known in commerce, and distinguished
by the place of their production, ‘Provence oil’ is the most esteemed; ‘Florence oil’
and ‘Lucca oil’ are also of very fine quality; ‘Genoa oil’ comes next, and then
‘Gallipoli oil,’ which forms the mass of what is used in England; ‘Sicily oil,’ which
has a slightly resinous flavour, is very inferior; and ‘Spanish oil’ is the worst
imported.
Prop., &c. Olive oil is a nearly inodorous, pale greenish-yellow, unctuous fluid,
with a purely oleaginous taste, peculiarly grateful to the palate of those who
relish oil. It does not suffer active decomposition at a heat not exceeding 600°
Fahr.; and when cooled to 36°it congeals into a granular solid mass. It is very
slightly soluble in alcohol, but its solubility is increased by admixture with castor
oil. It is soluble in 1 1⁄ 2 part of ether. When pure it has little tendency to become
rancid. Sp. gr. ·9170 to ·9173; ·9192, at 53 1⁄ 2° (Saussure); ·9176, at 59°
(Heidenreich); and ·9109, at 77° Fahr. (Saussure). Prod. 32%, of which 21% is
furnished by the pericarp, and the remainder, which is inferior, by the seed and
woody matter of the fruit.
Pur. Olive oil, with the exception of that of almonds, being the most costly of
the ordinary fixed oils of commerce, is, consequently, the one most subject to
adulteration. Nut, poppy, rape, and lard oil, are those most commonly used for
this purpose. Refined tallow olein, including that obtained from the ‘knackers’
yards’ of Paris, is said to have been used in the same way. The addition of any
other oil to olive oil renders it far less agreeable to the palate, and, by increasing
its tendency to rancidity, much more likely to offend and derange the stomach
and bowels of those who consume it. Parties who indulge themselves in the use
of this luxury would, therefore, do well to ascertain that what they purchase is
pure. When pure, and also fresh, olive oil is most wholesome as an article of food
or us a condiment.
The detection of the sophistication of salad oil is a matter of no great
difficulty. The palate of the connoisseur will readily perceive the slightest variation
in the quality of his favourite condiment. Other methods, however, of a more
accurate and certain description, and of more general application, are adopted.
Amongst these, in addition to those mentioned above, are the following:—
 a. When pure olive oil is shaken in a phial, only half filled, the ‘bead’ or
bubbles rapidly disappear; but if the sample has been mixed with poppy or other
oil, the bubbles continue longer before they burst.
b. Olive oil congeals at 36° Fahr., and is completely solidified when a small
bottle containing it is surrounded by ice, or a freezing mixture; but when mixed
with poppy oil, it remains partly liquid, even when the latter forms only 1-4th of
the mass; if more than 1-3rd of poppy oil is present, it does not solidify at all,
unless cooled much below the freezing point of water.
c. (Ph. E.) When olive oil is “carefully mixed with 1⁄ 12th part of its volume of
a solution of 4 oz. of mercury in 8 fl. oz. 6 dr. of nitric acid (sp. gr. 1·500), it
becomes in 3 or 4 hours like a firm fat, without any separation of liquid oil.”
d. M. Pontet recommends the mercurial solution to be made by dissolving 6
parts of mercury in 7 1⁄ 2 parts of nitric acid (sp. gr. 1·35), without heat; of this
solution he adds 1 part to every 48 parts of the oil, and well shakes the mixture
every 30 minutes, until it begins to solidify. This it does after about 7 hours in
summer and 4 or 5 hours in winter, and when the oil is pure it will have formed,
in 24 hours, a mass so hard that some little force must be employed to thrust a
glass rod into it. The other edible oils do not furnish a hard mass with nitrate of
mercury. The solidity of the mass is exactly in proportion to the quantity of
foreign oil present. When the sophistication is equal to 1-8th of the whole, a
distinct liquid layer separates; when the mixture contains half its volume of an
inferior oil, one half only of the mixture becomes solid, and the other half
continues liquid. A temperature of about 90° Fahr. is the best to cause the oil and
coagulum to separate perfectly from each other. When the oil has been
adulterated with animal oil, the mixture solidifies in about five hours; but in this
case the coagulum consists of the animal oil, whilst the olive oil floats on the
surface, and may be decanted for further examination. This coagulum, on being
heated, exhales the well-known odour of rancid fat or melted tallow.
e. Dr Ramon Cordina Langlies states that the best reagent for the
examination of olive oil is that of Hauchecorne.
This reagent is composed of three parts of pure nitric acid at 40° with one
part of distilled water. The following is Dr Langlies’ process for proving that olive
oil does not contain seed oil, and more especially cotton oil:—
He mixes three grammes of the oil to be tested with one gramme of the
reagent in a test tube, or a small stoppered flask, and heats the liquid in a water
bath. If the oil is pure the mixture becomes clearer, and takes a yellow colour, like
purified oil; if it is adulterated with seed oil, it acquires the same transparency as
the pure oil, but becomes red. With 5 per cent. of seed oil the reddish colouring is
characteristic; with 10 per cent. it is decided. The reaction does not require more
than from 15 to 20 minutes.
The colouring of the oils lasts for three days.
Uses, &c. The dietetical uses of olive oil are well known. In Spain and Italy it
is commonly employed as a substitute for butter. It is highly nutritious, but is
digested with difficulty by some persons, and hence should be avoided by the
dyspeptic. Like almond oil, it is occasionally employed as a laxative and
vermifuge, and is, perhaps, one of the mildest known. In pharmacy it is
extensively employed in the preparation of cerates, liniments, ointments, and
plasters.—Dose. For an adult, 1⁄ 2 to 1 wine-glassful as a mild aperient; for an
infant, 1⁄ 2 to 1 teaspoonful, mixed up with an equal quantity of honey, syrup of
roses, or syrup of violets. The white fibrous sediment which forms in the recently
expressed oil is the ‘AMURCA’ of Pliny, and was formerly highly esteemed in
medicine.
Oil, Olive, Droppings. Syn. Sweet-oil d. The ‘foots’ or ‘deposits,’ and the
‘drippings’ of the casks, cisterns, and utensils. Used for machinery, making soap,
&c.
Oil, Olive (Oxygenated). Syn. Oleum olivæ oxygenatum (Ph. Batav.), L. Olive
oil, 16 oz., is placed in a receiver surrounded with ice or very cold water, and
chlorine is slowly transmitted through it for several days, or until it becomes thick
and viscid, after which it is well washed with warm warm.
Oil, Palm. Syn. Palm butter; Oleum palmæ;, L. From the fruit of Elais
Guineensis, and E. melanococca, the Guinea oil palms. Orange or red coloured;
butyraceous or solid; smells of violets; unchanged by alkalies; bleached by
sunlight, age, exposure, chlorine, chromic acid, and oil of vitriol; melts at 117 1⁄ 2°
Fahr. Sp. gr. ·968. Demulcent. Used to colour and scent ointments, pomades, &c.;
but chiefly to make soap and candles. From Africa.
Oil, Pi′′ney. Syn. Piney tallow, P. dammar, P. resin. From Vateria Indica (Linn.)
or pænoe tree. Resinous flavoured, fragrant, made into candles. Sp. gr. ·926.
Oil, Pop′py. Syn. Oleum papaveris, L.; Oliete, Huile blanche, Fr. From the seeds
of Papaver somniferum (Linn.), or white poppy. Sweet; pale; dries and keeps well.
Used for salads, paints, and soaps; also (extensively) to adulterate almond oil, for
the inferior qualities of which it is frequently sold. It does not freeze until cooled
to 0° Fahr. Sp. gr. ·9243 to ·9245. Prod. 48% to 54%.
Oil of Pumpkin. Syn. Oleum cucurbitæ. Expressed from the seeds of the
pumpkin; a soothing application to piles.
 Oil, Rape. Syn. Colza oil, Brown o.; Oleum rapæ, L. From the seed of Brassica
napus (Linn.; cole or rape), and from Brassica campestris (Linn.; wild navew or
rape). Glutinous; buttery at 25° Fahr. Dries slowly; makes soft soaps and good
ointments, but bad plasters; smokes much in burning, unless well refined. Sp. gr.
·9135 to ·9136. Prod. 32%.
Oil, Refined or PALE RAPE (Oleum rapæ refinum, Ol. r. album) is prepared from
crude rape oil, by agitating it with about 2% of oil of vitriol, previously diluted
with about twice its weight of water, and, after 10 or 12 days’ repose, decanting
the clear oil, and filtering it through Canton flannel or felt. The quality is improved
by washing it with hot water or steam before filtration. Used for lamps, blacking,
and machinery; also extensively employed to adulterate both almond and olive
oil. It forms the common ‘SWEET OIL’ of the oilmen and druggists. Sp. gr. ·9136 to
·9140.
Oil, Seal. Syn. Oleum phocæ, L. From the hood seal, and harp seal, and other
species of Phocidæ. Pale seal oil is that which drains from the blubber before
putrefaction commences, and forms about 60% of the whole quantity of oil
obtained. It is very clear, free from smell, and, when recently prepared, not
unpleasant in its taste. Refined seal oil is the last, washed and filtered. Ranks close
after sperm oil. Brown or DARK SEAL OIL is that which subsequently drains from the
putrid mass. It is very strong-scented and nauseous, and smokes in burning. Both
are used for lamps and dressing leather. A full-grown seal yields 8 to 12 galls. of
oil; a small one, 4 to 5 galls.
Oil of Ses′amum. Syn. Oil of Gingelly (above).
Oil, Shark-liver. The lightest of the fixed oils. Sp. gr. ·865 to ·867.
Oil, Skate. Syn. Oleum ralæ, L. From the livers of Raia batis (Linn.), or
common skate, as cod-liver oil; also from Raia rhinobatus, or white skate, and
Raia clavata, or thornback. Often sold and mixed with cod-liver oil.
Oil, Spermace′ti. Syn. Sperm oil; Oleum cetacei, L. From the ‘head matter’ of
Physeter macrocephalus, or spermaceti whale; a species once common in all the
principal seas, but now chiefly confined to the Southern Ocean. It is very limpid,
smells little, and burns well; and has long been reputed the best oil for lamps and
machinery, as it does not thicken by age or friction. It is frequently adulterated
with refined seal oil. Sp. gr. ·875.
Oil, Sun′flower. Syn. Oleum helianthi, L. From the seeds of Helianthus
annuus and H. perennis. Clear, pale yellow, tasteless; thickens at 60° Fahr. Used
for salads and lamps. Sp. gr. ·9261. Prod. 15%.
Oil, Teel. See Oil, Gingelly.
 Oil, Tobac′co-seed. Syn. Oleum tabaci (expressum), L. From the seeds of
Nicotiana tabacum (Linn.), or true tobacco plant. Pale; dries well; equal to nut oil.
Its production has recently been carried on with considerable success in some
parts of Russia. Sp. gr. ·9232.
Oil of Touloucou′na. See Oil, Kundah.
Oil, Train. See Oil, Whale.
Oil, Wal′nut. Syn. Oleum juglandis, O. nucis j., L. From the kernels of the nuts
of Juglans regia (Linn.), or common walnut tree. Soon gets rank; dries well. Used
in paints, and occasionally in plasters. When ‘cold drawn’ and washed it is
sometimes eaten with salad. Sp. gr. ·9260 to ·9262. Prod. 48% to 52%.
Oil of Wax. Syn. Butter of wax; Oleum ceræ, L. From beeswax, by quick
distillation in a close vessel. Butyraceous. By rectification along with quicklime it
yields a liquid oil.
Oil, Whale. Syn. Train oil, Whale-train o.; Oleum balænæ, O. ceti, L. From the
blubber of the Balæna mysticetus (Linn.), or the common or Greenland whale, by
heat. Coarse; stinking. Southern whale oil is the best. Used for lamps, machinery,
&c. Sp. gr. ·9231. Prod. per fish, about 1 1⁄ 2 ton for each foot of bone.
Oil of Wheat. Syn. Oleum tritici, L. From bruised Colne wheat, with heat. In
chilblains, ringworm, and several other skin diseases.
Oil of Wine-stones. Syn. Grape-stone oil; Oleum vitis viniferæ lapidum, L. From
the seeds of grapes, separated from the marc. Pale yellow, bland, emollient. Used
for salads and lamps. Sp. gr. ·9202. Prod. 14% to 18%.
⁂ The numbers given above, under ‘products,’ unless when otherwise
stated, refer to the respective fruits, kernels, nuts, seeds, &c., deprived of their
husks, pods, shells, and every other portion destitute of oil.
OILS (Medicated). Syn. Olea cocta, O. infusa, O. medicata, L. These are
prepared by infusion or decoction. The bruised ingredients are either simply
digested in 2 to 4 times their weight of olive oil for some days, or they are gently
boiled in it until they become dry and crisp, great care being taken that the heat
towards the end of the process is not greater than that of boiling water. As soon
as the process is complete, the oil is allowed to drain from the ingredients, which
are then (if necessary) submitted to the action of the press. The product is
commonly run through flannel or a hair sieve whilst still warm, after which it is
allowed to repose for a week or ten days, when the clear portion is decanted from
the dregs. The green or recent plants are usually employed for this purpose, but,
in many cases, the dried plants, reduced to powder, and digested for 6 or 8 hours
in the oil, at the heat of hot water, with frequent agitation, yield a much more
valuable product. They are nearly all employed as external applications only.
⁂ The following are the most important preparations of this class:—
Oil of Adder’s Tongue. Syn. Oleum ophio glossi, L. From the herb, as OIL OF
BELLADONNA. A popular vulnerary.

Oil of Ants. Syn. Oleum formicarum. Digest 4 oz. of ants in 16 oz. (by weight)
of olive oil with a gentle heat, and strain.
Oil of Bal′sam Apple. Syn. Oleum balsaminæ. Prep. Balsam apple (deprived of
seeds), 1 oz.; oil of almonds, 4 oz.; digest and strain.
Oil of Belladon′na. Syn. Oleum belladonnæ (P. Cod.), L. Prep. From the fresh
leaves, bruised, 1 part; olive oil, 4 parts; digested together at a gentle heat until
the moisture is evaporated; the oil is then strained off with pressure, and filtered.
Oil of Cantha′rides. Syn. Oleum cantharidis, O. cantharidibus, L. Prep. (P. Cod.
1839). From Spanish flies (powdered), 1 part; olive oil, 8 parts; as Oil of
Belladonna. Stimulant and rubefacient. Used as a dressing to indolent sores,
blisters, &c.; and in dropsy, rheumatism, gout, &c., Oil of the oil-beetle (Meloe
proscarabæus—Linn.) is prepared in a similar manner.
Oil of Cap′sicum. Syn. Oleum capsici, L. Prep. (Dr Turnbull.) From powdered
capsicum or Cayenne pepper, 4 oz., olive oil, 1 pint; digested together for 6 hours,
with heat, and strained. Stimulant; rubefacient in colic, cholera, &c.
Oil of Cham′omile. Syn. Oleum anthemidis, Ol. chamæmeli, L. From the dried
flowers (rubbed to pieces), 1 part, olive oil, 8 parts; digested together, with heat,
for 6 hours. Stimulant, emollient, and vermifuge.
Oil of Col′ocynth. Syn. Oleum colocynthidis, L. From the pulp, as Oil of
Chamomile. Diuretic. In dropsy, neuralgia, rheumatism, worms, &c.
Oil of Earth′worms. Syn. Oleum lumbricorum. (E. Ph. 1744.) Washed
earthworms, 1⁄ 2 lb.; olive oil, 1 1⁄ 2 pint; white wine, 1⁄ 2 pint. Boil gently till the
wine is consumed, and press and strain.
Oil of Elder-flowers. Syn. White oil of elder; Oleum sambuci album, O.
sambucinum (P. Cod.), L. Prep. From the flowers, as Oil of Chamomile. Emollient and
discussive.
Oil of Elder-leaves. Syn. Green oil, Green oil of elder, Oil of Swallows; Oleum
viride, O. sambuci viride, L. Prep. 1. Green elder leaves, 1 lb.; olive oil, 1 quart; boil
gently until the leaves are crisp, press out the oil, and again heat it till it turns
green.
 2. As before, but by maceration, at a heat under 212° Fahr. More odorous
than the last.
3. Elder leaves, 1 cwt.; linseed oil, 3 cwt.; as No. 1.
Obs. The last form is the one usually employed on the large scale. It is
generally coloured with verdigris, 1⁄ 2 lb. to the cwt., just before putting it into the
casks, and whilst still warm; as, without great skill and a very large quantity of
leaves, the deep-green colour so much admired by the ignorant cannot be given
to it. The oil is got from the leaves by allowing them to drain in the pan or boiler
(with a cock at the bottom), kept well heated. Emollient; in great repute among
the vulgar as a liniment, in a variety of affections.
Oil of Fen′ugreek. Syn. Oleum fœnugræci, L. Prep. (P. Cod.) From the seeds,
as Oil of Cantharides or of CHAMOMILE. Emollient and resolvent.
Oil of Fox′glove. Syn. Oleum digitalis, L. Prep. (P. Cod.) From the fresh
leaves, as Oil of Belladonna. Used as an application to chronic ulcers and
indurations, painful swellings &c. As usually met with, it is nearly inert.
Oil of Garden Night′shade. Syn. Oleum solani, L. Prep. (P. Cod.) From the
leaves, as Oil of Belladonna. Anodyne and discussive.
Oil of Gar′lic. Syn. Oleum allii infusum, L. From garlic, as Oil of Belladonna.
Used as a liniment in deafness, diarrhœa, infantile convulsions, palsy,
rheumatism, &c.
Oil, Green. Syn. Oleum viridi, L. From bay leaves, origanum, rue, sea
wormwood, and elder leaves, of each 2 1⁄ 2 oz.; olive oil, 1 quart; as Oil of Elder.
Detergent, stimulant, and resolvent. Green oil of elder is now usually sold for it.
Oil of Hem′lock. Syn. Oleum conii, L. Prep. (P. Cod.) As Oil of Belladonna.
Anodyne and emollient; in painful ulcers, glandular tumours, &c.
Oil of Hen′bane. Syn. Oleum hyoscyami, L. Prep. (P. Cod.) As Oil of
Belladonna. Used as the last, in various painful local affections.
Oil Iodizeo, Marshall’s. Syn. Oleum iodatum. Prep. Oil of almonds, 15 parts;
iodine, 1 part. Triturate and digest till dissolved.
Oil of Ju′′niper (by Infusion). Syn. Oleum juniperi infusum, L. From the
crushed berries, as Oil of Belladonna. Diuretic and vulnerary; in frictions, &c.
Oil of Lil′ies. Syn. Oleum liliorum, L. From white lilies, 1 lb.; olive oil, 3 lbs.;
as Oil of Belladonna. Emollient; used to soften and ripen tumours, indurations, &c.
 Oil of Mel′ilot. Syn. Oleum meliloti, L. As the last, avoiding much heat.
Emollient and resolvent.
Oil of Mu′cilages. Syn. Oleum mucilaginum, O. cum mucilaginibus, L. Prep. 1.
(Ph. L. 1746.) Marshmallow root, 1⁄ 2 lb.; linseed and fenugreek seed, of each,
bruised, 3 oz.; water, 1 quart; boil 1 hour, add of olive oil, 2 quarts, and boil until
the water is consumed.
2. Fenugreek seeds, 8 oz.; linseed oil, 1 quart; infuse a week, and strain.
Once a highly popular emollient application in various local affections.
Oil of Mu′dar. Syn. Oleum mudaris, L. From mudar bark (in coarse powder), 1
dr.; warm olive oil, 1⁄ 4 pint; digest 24 hours and strain. Used as an application to
cutaneous ulcers, the bites of venomous animals, &c., and as a friction in worms.
Oil of O′′pium. Syn. Anodyne oil, Opiated o.; Oleum opiatum, L. Prep. From
opium (in powder), 1 dr.; olive oil, 2 1⁄ 2 fl. oz.; digest at a gentle heat, with
frequent agitation, for 5 or 6 hours. The powder should be rubbed in a mortar
with a few drops of the oil before adding the remainder. As a local anodyne. The
above is the only reliable formula for this preparation. Others are extant, but
whilst the products of several are much stronger, those from others have only 1-
5th or 1-6th the strength.
Oils, Ozonised. (Dr Thompson.) Syn. Oleo ozonata. Prep. Pass oxygen gas
into the oil (cocoa nut, sunflower, cod-liver oil, &c.) until it will dissolve no more.
Then expose for a considerable time in the direct rays of the sun. Used in
phthisis.
Oil of Pel′litory. Syn. Oleum pyrethri, L. From bruised pellitory root, as OIL OF
BELLADONNA. Used as the last.

Oil of Black Pep′per (by Infusion). Syn. Oleum piperis infusum, L. From
black pepper, in coarse powder, as Oil of Capsicum. Stimulant and rubefacient; in
frictions.
Oil of Poison Oak. Syn. Oleum rhois toxicodendri, L. From the leaves, as OIL
OF BELLADONNA Externally; in paralysis, &c.

Oil of Rhu′barb. Syn. Oleum rhei, L. From rhubarb (in powder), 1 part; oil of
almonds, 8 parts; digested together in a gentle heat for 4 hours, and strained,
with expression. As an application to indolent ulcers, and as a friction over the
abdomen in diarrhœa, English cholera, &c., or as a laxative when the stomach will
not bear medicine.
Oil of Ro′′ses. Syn. Oleum rosæ, O. rosaceum, O. r. infusum, O. rosatum, L.
Prep. From the fresh petals, pulled to pieces, crushed, and digested for 2 or 3
days in the sun, or a warm situation, in 4 times their weight of olive oil, and then
pressed; the process being repeated with fresh roses. Ph. E. 1744 and P. Cod. are
nearly similar. Almond, BEN, or OLIVE OIL, coloured with ALKANET, and scented with
attar of roses, is now almost universally sold for it. Used for the hair.
Oil of Rue. Syn. Oleum rutæ (infusum), L. Prep. (P. Cod.) From fresh rue,
bruised, as Oil of chamomile. Reputed antispasmodic, emmenagogue, stimulant,
and vermifuge. In frictions.
Oil of St John’s Wort. Syn. Oleum hyperici (Ph. L. 1746), O. h. simplex,
Balsamum h., L. From the flowers, 1 part; olive oil, 6 parts; digested together until
the oil is well coloured. Antispasmodic, stimulant, and resolvent. A mixture of
equal parts of RAPE OIL and GREEN ELDER OIL is usually sold for it.
Oil of Scam′mony. Syn. Oleum scammonii, O. purgans, L. Prep. (Van Mons.)
From scammony (in powder), 1 dr.; hot oil of almonds, 3 fl. oz.; triturate together
until cold, and the next day decant the clear portion.—Dose, 1⁄ 2 to 1 table-
spoonful.
Oil of Stramo′′nium. Syn. Oleum stramonii, L. Prep. (P. Cod.) From the
leaves of thorn apple or stramonium, as OIL OF BELLADONNA. Anodyne and
discussive; as an application to painful tumours, joints, &c.
Oil of Tobac′co (by Infusion). Syn. Oleum tabaci, O. t. infusum, L. From
fresh tobacco leaves (bruised), like OIL OF CHAMOMILE. As an application in
ringworm, irritable ulcers, pediculi, &c.; and as a friction in itch, neuralgia, painful
indurations, &c. It must be used with extreme caution, as it is poisonous.
Oil of Tooth′wort. Syn. Oleum squamariæ, L. From the herb of Lathræa
squamaria (Linn.), as Oil of St John’s wort. Astringent and vulnerary. This must
not be confounded with another preparation sometimes called ‘Oil of toothwort’
(Oleum plumbaginis Europææ),and which has been occasionally used in itch, as the
latter is acrid and apt to cause much irritation.
Oil of Worm′wood. Syn. Oleum absinthii, L. From the fresh herb, as OIL OF
LILIES. The P. Cod. and Ph. Wurtem. order only part of the herb to 8 parts of oil.
Applied to the abdomen in dyspepsia, diarrhœa, heartburn, worms, &c. It is
seldom used in this country.
OILS (Mineral). Syn. Hydrocarbon oils. An important class of liquids,
consisting solely of carbon and hydrogen—the elements of ordinary coal-gas, and
obtained by the distillation of coal, lignite, petroleum, and other bituminous
substances. For the purposes of illumination, many of these oils are in most
respects superior to the fixed or fat oils containing oxygen. They give a whiter
and more brilliant light, and are produced at a much lower cost. The lamps in
which they are burnt, when properly constructed, are less liable to get out of
order than those adapted for the combustion of fat oils, and require less attention
when in use. The experiments of Dr Frankland on the relative value of the
ordinary illuminating agents[57] prove that the mineral oils are cheaper than all
other portable illuminating agents in common use, and that they give, while
burning, the largest amount of light with the least development of heat, and the
smallest production of carbonic acid. With the oils adapted for burning in lamps
other oils are produced. Some are very volatile and highly inflammable, and the
safety of the burning oils depends on their proper extraction. These volatile
liquids, when isolated, are used in the arts as substitutes for spirits of turpentine,
as solvents for various substances, and to increase the illuminating power of coal-
gas. Others are of a greasy nature, and are too heavy to be conveniently used in
lamps. These, however, are well adapted for lubricating fine machinery, and are
extensively employed instead of sperm oil by the cotton manufacturers of
Lancashire. When the more volatile ingredients are separated from the burning
oils, the latter are perfectly safe. Most of the mineral burning oils now in use are,
we believe, free from danger in this respect. (See Tests, below.)
[57] See article Illumination.

Hist. For many years the manufacture of burning oils by the distillation of
bituminous schists has been extensively carried out on the Continent, but the
discovery which formed the foundation of the modern manufacture was made
nearly thirty years ago by our countryman, Mr James Young. This gentleman took
the lease of a spring of petroleum in 1847, and after numerous experiments
succeeded in obtaining two useful oils from the crude liquid; the one being
adapted for lubricating machinery, and the other for burning in lamps. The almost
total cessation of the flow of petroleum terminated the business after two years’
working, and led Mr Young to institute a series of experiments to try if petroleum
could be produced artificially by the destructive distillation of coal. These
experiments resulted in the discovery of an oil which Mr Young named ‘Paraffin
oil,’ as it had many of the chemical properties of the solid body of paraffin,
discovered twenty years before by Reichenbach in beech-wood tar. Young’s patent
(dated Oct. 7, 1850) involved the slower distillation of coals, at a lower
temperature than had hitherto been employed for the purpose, and this novelty in
practice was followed by the novel result of a copious production of liquid
hydrocarbons. The gas or cannel coals were found to yield the liquids in largest
quantities, that variety known as Boghead coal or Torbane Hill[58] mineral being
specially adapted for the patented process. (See Paraffin oil, below.) Soon after
Young’s discovery native petroleum was brought from Rangoon, and purified by
distillation, so as to produce oils very similar to the coal products. During the last
few years, however, rich sources of petroleum have been discovered in North
America, and from whence are imported the greater part of the vast quantities of
petroleum oil (both for burning and lubricating purposes), together with the
paraffin spirit, or naphtha, which are consumed in this country.
[58] This species of coal is now exhausted.—Ed.

In the following table are given the quantities of these substances sent into
England and Scotland during the year 1875:—

Refined burning Oil. Lubricating Oil. Residuum. Petroleum Spirit.

Barrels. Cases. Barls. & Casks. Barrels. Cases. Barrels.
London 169,762 3,250 2,511 1,000 ... 53,173
Liverpool 95,853 2,830 300 29,358 ... 30,913
Hull 20,226 8 ... ... ... ...
Bristol 36,889 1,392 ... ... ... 17,203
Clyde and Leith 4,233 4 535 9,387 ... ...
——— ——— ——— ——— ——— ———
Total 326,963 7,484 3,346 39,745 ... 101,289

This amounts to about 17 millions of gallons. In 1874 it exceeded 20 millions

of gallons, but the stock in hand at the end of 1874 was about 5 millions of
gallons, and the end of 1875 was only 1 1⁄ 2 million. The difference was mainly
due to overtrading in 1874, which brought refined petroleum to the lowest price
yet known in England, viz. 7 3⁄ 4d. per gallon in December, 1874, and checked its
subsequent importation.[59]
[59] W. Matthieu Williams.

Tests, Precautions. The Sanitary Commission of the ‘Lancet’ took as the limit
of safety an oil that gave off inflammable vapour when heated to 130° Fahr., and
this has been generally accepted by dealers. If an oil gives off inflammable
vapours before being heated up to 130°, it is considered unsafe for domestic use.
1. The plan for testing this, recommended in the ‘Lancet,’ is to heat a portion
of the suspected oil in a gallipot placed in boiling water, ascertaining by a
thermometer suspended in the oil the temperature at which it will take fire on the
surface when a lighted wax vesta is applied to it. This is a troublesome and
dangerous process, and has little practical value.
2. A rough-and-ready method of testing the inflammability of a sample is to
pour a little out on a dry flat board, and try whether it can be ignited readily by a
lighted paper. If it catches fire like turpentine or brandy, the oil is dangerous.
 3. The following plan, proposed by Mr Tegetmeier, requires no scientific
knowledge and no apparatus but what is to be found in every house, while it is
sufficiently accurate for all practical purposes:—
“Take an earthenware dish, holding about half a pint (a breakfast cup will
do), fill the cup full from a kettle of boiling water, pour this into an earthenware
quart jug, then fill the same cup again with boiling water from the kettle, and
pour it also into the quart jug, then fill the cup with cold water, put it into the jug,
shake the jug to mix the hot and cold water, then pour the tepid water from the
jug into the cup till the cup is half full, then pour about a table-spoonful of the oil
to be tested on the tepid water in the cup, take the oil-can with the oil out of the
room, then touch the surface of the oil in the cup with a lighted splinter of wood,
or a match without sulphur. If the match causes a flash of flame to appear on the
surface of the oil, the oil is below the standard of safety, and should not be used;
if no flame appears, the oil is up to the standard. We may mention that in this
trial no time should be lost after pouring the boiling water from the kettle, as the
water may get too cold, but the whole may be gone through in from two to three
minutes. It is well to have a saucer at hand, and if the oil should be a bad oil, and
ignite with the match, place the saucer on the mouth of the cup, and the flame is
extinguished. This trial should be done by daylight, and at a distance from a fire,
and the directions must be followed exactly in the order as given above.”
4. Provided that the oils to be examined have been produced by careful
fractional distillation, their relative volatility, as indicated by their specific gravity,
shows to a great extent the facility with which they ignite. The lightest oils are
more volatile and more easily inflamed than those which are heavier. Oils much
under ·800 inflame directly a lighted match is thrown into them, whereas oils at
about ·815 to ·823 (if unmixed products) cannot be set on fire in this manner.
The specific gravity test cannot, however, be depended on to determine the
inflaming point of any commercial oil. A heavy oil, badly rectified, may contain a
proportion of very volatile vapour, and have a low inflaming point; whereas a
much lighter oil may be perfectly safe, from its having the more volatile portions
carefully removed.
5. (Van der Weyde.) The oil to be tested is placed in a graduated tube closed
at one end; the open end is then closed with the finger, and is then placed mouth
downwards in a vessel of water that is heated from 43°—44° C. The vapour from
the portion volatilised at this temperature then collects in the upper part of this
tube, and expels a corresponding quantity of oil. See Petroleum.
In Great Britain petroleum is defined by Act of Parliament as being any oil
which gives off all inflammable vapour at a temperature less than 100° F.
 To prevent accidents with paraffin or petroleum lamps, the following
precautions ought to be observed:—
The lamps should be filled and trimmed by daylight.
They should never be overfilled; the oil should not be allowed to come into
contact with the metal work of the burner.
Any portion of oil spilled on the outside of the lamp should be carefully wiped
away.
When not in use the wick should be turned down into the wick-holder.
⁂ The principal products noticed below rank high among the numerous
varieties of mineral oil now in the market, but there are doubtless many others
equally good and safe. Their properties are described in accordance with the
results obtained by Mr W. B. Tegetmeier, who has devoted much time to the
examination of the mineral oils:—
Oil, Al′bertite. From ‘Albertite,’ a lustrous black mineral found in New
Brunswick. A sample was shown in the Colonial Department of the International
Exhibition of 1862, but the oil has not yet appeared in the English market.
Prop. Odour very slight; illuminating power high; boiling point 338° Fahr., or
126° above that of water.
Oil, American. See Petroleum oil (below).
Oil, Apyroec′tic. Syn. Non-explosive oil. A burning oil, introduced by F. Tall,
of Hull, and prepared, we believe, from American petroleum.
Prop. Slightly coloured; perfectly limpid; odour slight, but not perceivable
during combustion. The most remarkable property of this oil is that, in spite of its
limpidity, the point at which it gives off inflammable vapour is 180° Fahr., or 80°
above the requirements of the Petroleum Act.
Oil, Bel′montine. From Rangoon tar, or Burmese petroleum, by distillation;
superheated steam being employed as the heating agent.
Prop. Colourless; odour not unpleasant; sp. gr. ·847; but although so heavy,
the oil is altogether free from viscosity, and will rise rapidly in a comparatively
long wick; inflaming point 134° Fahr.; burns with an exceedingly white light, and
possesses a very high illuminating power.
Obs. The distillation of the Rangoon tar is carried on by Price’s Patent Candle
Company under a patent. Besides the above lamp oil, several beautiful and useful
products are obtained. At first there comes over a very volatile liquid, termed
Sherwood oil, used as a detergent for removing grease from fabrics, cleaning
gloves, &c.; then comes the Belmontine oil, already noticed; then two lubricating
oils, the one light and the other heavy; and, last of all, when the temperature is
considerably elevated, the beautiful white, translucent solid known as Belmontine,
distils over. This last is a kind of paraffin, and is used for making ornamental
candles.
Oil, Caz′eline. An excellent burning oil, probably prepared from American
petroleum, introduced by Cassell, Smith, and Co., of London.
Prop. Bright, limpid, with scarcely a trace of colour; odour very slight, and
quite free from any objectionable character; sp. gr. ·805; lowest point of ignition
144° Fahr.; burns with a pure white light, free from smoke and smell.
Oil, Col′zarine. A heavy hydrocarbon oil, adapted for burning in lamps
constructed from the old ‘Moderators’ and ‘Carcels,’ formerly so much used for the
fat oils.
Prop. Limpid; quite inodorous; of a pale amber colour; sp. gr. about ·838;
temperature at which the vapour can be permanently ignited, 250° Fahr. Tested in
the altered moderator, it gives an intense white light, without smoke or smell.
Compared with vegetable colza oil, its illuminating power is in the proportion of 3
to 2.
Obs. This oil is manufactured by Cassell, Smith, and Co., under Martin’s
patent for the modification of mineral oils, to fit them for burning in lamps where
‘colza’ and other vegetable and animal oils have been usually consumed. Similar
oils are prepared by other firms.
Oil, Machin′ery. Syn. Lubricating oil, Shafting o., Spindle o. The heavier
hydrocarbon, oils obtained in distilling coal, shale, and petroleum, have almost
superseded the fat oils for lubricating purposes. They have no chemical action on
the ordinary metals, and are not affected by cold. The lightest of these
comparatively heavy oils are used for spindles, or other kinds of rapid machinery;
the heaviest for the bearing parts of heavy machinery; and those of an
intermediate character for such things as printing-presses, agricultural steam-
engines, &c. In America and on the Continent this oil is also used for making gas.
The firm of Whitmore and Craddock is favorably known for the manufacture and
purification of these machinery oils. See Oil, Belmontine (above), and Oil, Paraffin
(below).
Oil, Pa′raffin. Syn. Paraffine oil. This name was given by Mr Young to the oil
produced by the distillation of cannel coal, Boghead coal, &c., at a temperature
considerably lower than that employed in the manufacture of illuminating gas.
The following is a brief outline of Mr Young’s process:—
 Manuf. (Young’s patent.) Boghead coal, broken into small fragments, is
introduced into perpendicular tubes or retorts, about eleven feet in height, by
conical hoppers at their upper extremities. Four of these tubes constitute a set,
being built into one furnace, and charged by a single workman. They pass
completely through the furnace, and are closed below by dipping into shallow
pools of water, while the openings into the hoppers above may be shut by
spherical valves. The coal in each tube is gradually heated as it descends to that
part which passes through the furnace, and when it reaches the bottom of the
tube it has parted with its volatile constituents, and is raked away as refuse, the
coal from above descending as it is removed. Thus, the action of these
perpendicular retorts is continuous, and the distillation goes on uninterruptedly
both day and night. The vapours produced are conducted by iron tubes to the
main condensers, which consist of a series of syphon pipes freely exposed to the
air. The quantity of incondensible gas formed is inconsiderable; and it is this
result, so different from that obtained in the ordinary gasworks, that marks the
great value of Young’s process. The crude oil, a dark-coloured, thick liquid, is then
distilled to dryness in large iron cylindrical stills, and is thus freed from the excess
of carbon which is left behind as coke. The oil, after distillation, is further purified
by being acted upon by strong sulphuric acid (oil of vitriol), which chars the
principal impurities, and causes them to subside in the form of a dense black,
heavy acid tar. To separate the remaining impurities, and that portion of the
sulphuric acid which remains in the oil, it is next subjected to the action of caustic
soda. As thus purified, the paraffin oil contains four distinct commercial products.
To effect their separation, the process of fractional distillation is first employed.
The first elevation of temperature drives over the lighter and more volatile
portions, which, when purified by a subsequent distillation, yields the fluid known
as ‘paraffin naphtha,’ ‘petroleum spirit,’ ‘benzoline.’ This product is used as a
substitute for ‘turps,’ as a solvent for india rubber for cleaning gloves, and for
burning in those naphtha lamps so much employed by costermongers, and
workmen in railway tunnels and similar situations. On the perfect separation of
this naphtha the safety of the burning oil depends. This burning oil, the ‘paraffin
oil’ of commerce, comes over at a much higher temperature than the naphtha. It
is a perfectly safe lamp oil, and has a greater illuminating value than any other oil
in the market. Its properties are noticed below. The third product in point of
volatility is a comparatively heavy liquid (machinery oil), largely used for
lubricating purposes in the Lancashire factories. From this oil, and others which
come over at a very high temperature, the fourth commercial product is
separated by the action of artificial cold. This last product is the beautiful
translucent solid, paraffin, now much used as a candle material.[60] (See Oil,
Paraffin, Petroleum.)
[60] For a detailed account of the processes carried on at the Bathgate
works, see Mr Tegetmeier’s paper in ‘England’s Workshops,’—Groombridge and
 Sons.

In the preparation of paraffin oil, from native petroleum, the oil is obtained
by direct distillation from the petroleum, and subsequently separated from the
more or less volatile hydrocarbons (the paraffin naphtha, the lubricating oils and
the solid paraffin) that are associated with it by fractional distillation as in Young’s
process; whereas, when procured from bituminous minerals, it is derived from the
tar or crude oil, which has to be previously extracted from the bituminous matters
by destructive distillation. There are various methods for obtaining this tar or
crude oil, which, although differing in detail, are in general principles very similar
to that described in Young’s patent. Thus, whilst in many works closed horizontal
retorts are employed, in other establishments vertical ones, to the bottoms of
which are attached receptacles for the receipt of the exhausted coal or other
material as it falls from the retort, the same as in Young’s apparatus, are
extensively adopted. When horizontal retorts are employed they are made of cast
iron, and vary in length from 8 to 10 feet, being from 28 to 34 inches wide and
from 9 to 14 inches deep. The charge is introduced by an opening in the end of
the retort, by which aperture the exhausted residue is removed when necessary.
This aperture is closed by a tightly fitting cast iron cover while the distillation is
going on. At the other end of the retort is a pipe for carrying off the products of
distillation. This communicates with a larger pipe, and this latter with the
condensing apparatus. A number of these retorts are set together in a row, with a
furnace at one end, and flues extending beneath the retorts, while the upper
parts of the retorts are covered with brickwork, to prevent the oil vapours from
being decomposed by the heat of the waste furnace gas passing to the chimney
through the flues above the retorts.
The gaseous products of the distillation of the tar, leaving the retort by the
exit tube already described, are cooled by being made to pass through a number
of iron pipes exposed to the air, or surrounded by water, and thus becoming
condensed pass into a reservoir in the form of the oil, which forms the material
from which the various hydrocarbons are separated by fractional distillation.
Accompanying the oil vapours are certain uncondensable gases; these escape
through a properly contrived outlet which is made in the condensing pipes; in
some works these escaping gases are utilised as fuel, and in others for purposes
of illumination.
In other works superheated steam is driven into the retorts during the
process of distillation; but although this has the effect of sweeping the oil vapour
more quickly out of the retort into the condenser, it is questionable whether this
advantage covers the extra cost of the production of the steam.[61]
[61] Payne’s ‘Industrial Chemistry.’ Edited by Dr Paul.
 In many parts of Germany the extraction of the crude oil or tar from
bituminous substances is effected in ovens. In these ovens the bituminous body is
thrown upon a layer of burning fuel which covers the bottom of the oven, the
result being that the bituminous matter is resolved into gaseous bodies which are
lost, and tar which flows downwards toward the burning fuel, which being
covered with a layer of clay is prevented from entering into violent combustion.
This method, however, is only had recourse to on a small scale, since it is found
that in most cases the tar obtained by means of it is not of a kind suited for
yielding paraffin and paraffin oils.
The preparation of the tar or crude oil from fossil fuel, of the character
already specified, constitutes one of the most delicate and difficult branches in
the manufacture of paraffin oils, and paraffin, &c. The chief sources of failure to
be avoided are the overheating of the oil vapour, and its consequent
decomposition (varying in amount) into useless gaseous products; and its
inefficient condensation.
It has been shown by Vohl that even when the construction of the retorts is
not of the best, an average yield of tar may be obtained by the proper
condensation of the vapours. “The complete condensation of the vapours of the
tar is one of the most difficult problems the mineral oil and paraffin manufacturer
has to deal with, while the means usually adopted for condensation, such as large
condensing surfaces, injection of cold water, and the like, have proved ineffectual.
It has often been attempted to condense the vapours of tar in the same manner
as those of alcohol, but there exist essential differences between the distillation of
fluids and dry distillation. In the former case the vapours soon expel all the air
completely from the still and from the condenser, and provided, therefore, that, in
reference to the size of the still and bulk of the boiling liquid, the latter be large
and cool enough, every part of the vapour must come into contact with the
condensing surfaces. In the process of dry distillation the process is entirely
different, because with the vapours, say of tar, permanent gases are always
generated. On coming into contact with the condensing surfaces a portion of the
vapours is liquefied, leaving a layer of gas as a coating, as it were, on the
condensing surface. The gas being a bad conductor of heat prevents to such an
extent the further action of the condensing apparatus, that a large proportion of
the vapours are carried on, and may be altogether lost. A sufficient condensation
of the vapours of tar can be obtained only by bringing all the particles of matter
which are carried off from the retorts into contact with the condensing surface,
which need neither be very large nor exceedingly cold, because the latent heat of
the vapours of tar is small, and consequently a moderately low temperature will
be sufficient to condense those vapours to the liquid state. The mixture of gases
and vapours maybe compared to an emulsion such as milk, and as the particles of
butter may be separated from milk by churning, so the separation of the vapours
of tar from the gases can be greatly assisted by the use of exhausters acting in
the manner of blowing fans. It is of the utmost importance in condensing the
vapours of tar that the molecules of the vapours be kept in continuous motion,
and thus made to touch the sides of the condenser. The condenser should not be
constructed so that the vapours and gases can flow uninterruptedly in one and
the same direction.”[62]
[62] B. Wagner.

An important condition for the safe and quiet distillation of the tar or crude
oil when obtained is that it should be free from water. Unless the removal of the
water is effectually accomplished, during its distillation, the tar may boil over, and
coming into contact with the fire under the still may give rise to an alarming
conflagration. The dehydration of the tar is effected in an apparatus constructed
for the purpose, consisting of an iron tank placed within a larger tank, a space of
about two inches intervening between the two tanks is filled with water, which is
heated to, and kept at a temperature of between 60° and 80° C., for 10 hours, by
the end of which time the ammoniacal water having separated from the lighter
tar is drawn off by a stop-cock placed at the bottom of the tank, whilst the tar is
decanted through a valve at the top.
In America the distillation of the natural petroleum oils is carried out in
cylindrical stills capable of holding as much as 1600 gallons each. The retorts
employed in the distillation of the tar or crude oils obtained from shale and other
bituminous compounds are often constructed of large cast-iron flanged pans,
each capable of containing from 1 1⁄ 2 to 3 tons of the oil, “and forming the body
of the retort. The pan is set in brickwork with flues running round the upper
portion, and beneath it is a perforated dome of brickwork, through which the
flame and hot gas from the furnace pass up round the bottom of the pan before
entering the flues by which the upper portion of the pan is heated. To the flange
of the pan is fitted a flanged cover having on one side a discharge pipe through
which the vapour is passed to the worm of the condenser. In the centre of the
cover is a manhole. The oil condensed in the worm is discharged through a pipe
into a receiver, and the uncondensable gas escapes through an ascending
pipe.”[63]
[63] Palen.

The processes to which the crude oil or tar and the natural petroleum are
next submitted differ only in the degree of treatment with certain agents to which
these products are subjected when, after similar methods of fractional distillation,
they have been isolated from each other. The benzoline and paraffin oils (both for
burning and lubricating purposes) separately yielded by the natural oils seldom
require purification, or if so in a minor degree only, whilst the same bodies as
obtained from the crude shale oil or tar must be submitted to various processes
of depuration before they are fit for the market. Thus, the crude petroleum or
burning oil derived from tar is characterised by a more or less dark colour and
disagreeable smell—properties which are partly due to the presence of carbolic
acid and its homologues. By agitating the paraffin oil with a solution of caustic
soda these objectionable substances are removed.
The oil, being next separated from the alkali by subsidence, and any remains
of the soda being removed from it by washing with water, is next mixed with an
aqueous solution of sulphuric acid in the proportion of 5 per cent. of acid of sp.
gr. 1·70. The acid removes from the oil certain basic substances derived from the
tar, which, like the carbolic acid, give to it a bad odour and a dark colour. In this
operation thorough admixture of the acid with the oil is important, and this is
generally effected by mixing the two in vessels furnished with puddles. After a
time, and when the mixture has separated into two layers, the upper one or the
paraffin oil is drawn off from the lower or acid one, and well washed with water;
in some instances lime water is used for the washing, in others the water is
impregnated with caustic alkali. With some samples of crude paraffin oil the
above operations have to be repeated two or three times, and even redistilled
before the oil becomes sufficiently pure and colourless for sale. When redistilled,
the last portions which come over are often found to yield some solid paraffin in
addition to that furnished by the first fractional distillation. The ‘paraffin,’
‘naphtha,’ ‘petroleum,’ ‘spirit,’ or ‘benzoline’ (by all of which names it is known),
which forms the more volatile portion of the tar, and which is the first to pass
over from the retort, is subjected to the same treatment as that used for burning
oil; as for the denser lubricating oil, which passes over after the burning portion,
this being freed from any of the latter, is set aside in a cool place, in order that
any solid paraffin it contains may crystallise out, and be separated from it.
The waste carbolate of soda resulting from the treatment of the oil with the
caustic alkali, being decomposed by sulphuric acid, the liberated carbolic acid is
utilised either as a disinfectant, or for saturating railway sleepers; and sometimes
as a source of certain tar colours; or it may be used in the manufacture of gas,
the soda which remains in the coke being extracted by lixiviation. The waste
sulphuric acid combined with the ammoniacal liquors that always accompany the
first stages of the distillation of the tar is made into sulphate of ammonia.
Prop. The paraffin oil of commerce is of a very pale amber colour; is bright,
perfectly transparent, and remarkably limpid. Its sp. gr. is ·823. Its point of
temporary ignition is 150° Fahr., that of permanent ignition being a few degrees
higher. Its odour is very slight. Its rate of combustion is slow, as may be inferred
from the absence of the lighter oils, as indicated by its high sp. gr. and inflaming
point. At the same time its limpidity proves the absence of the heavier oils, and
accounts for its rising through a long wick with freedom, and burning without
charring the cotton.
Oil, Petro′leum. Syn. Kerosene oil, Refined petroleum, Paraffin oil. Most of the
burning oils now in the market are derived from American petroleum. That
obtained from natural petroleum is now manufactured solely in America. The
native petroleums vary greatly in properties, and numerous methods of refining
are employed by the manufacturers. The Canadian petroleum contains
sulphuretted hydrogen, which imparts to it a very disagreeable smell, and is
difficult of removal. Some make use of both acids and alkalies, others employ
alkalies alone, and steam is applied at various degrees of heat. Some of the oils
produced are of excellent quality, but others are inferior, and do not ascend the
wick in sufficient quantity to afford a constant light. None of the native
petroleums contain carbolic acid and other impurities which exist in the oils
distilled from coals and shales; hence their purification is simple and
comparatively cheap. “The oil prepared from petroleum is almost colourless; it
has a specific gravity of about ·810, and when of good quality only a slight and
rather aromatic odour.” (Payen.) See Petroleum, and above.
Oil, Shale. As we have stated, products analogous to those derived from
cannel coal are obtained by the destructive distillation of bituminous shales and
schists, and lignites or brown coals. On the Continent the production of shale oils
has of late years declined considerably, owing to their unsuccessful competition,
in point of price, with the American petroleum oils. The oil obtained from
bituminous shale or from coal is generally of higher specific gravity than that
procured from petroleum; it is deeper in colour, and not so pleasant in smell.
OILS (Mixed). Syn. Compound oils; Olea composita, Olea mixta, L. Under these
names are commonly included various mixtures of oils and other substances that
possess an unctuous appearance. When not otherwise stated, they are prepared
by simply agitating the ingredients together, and, after a sufficient time,
decanting the clear portion, which, in some cases, is then filtered. A few of them
only possess any importance. Some of them are highly esteemed as remedies
among the vulgar, and the use of others is confined to veterinary medicine.
The following include the principal mixed oils of the shops, to which the
names of a few other compounds, which are frequently called ‘oils’ by the
ignorant, are added, for the purpose of facilitating a reference to them:—
Oil of Turpentine, Sulphurated. Syn. Oleum terebinthinæ sulphuratum. Prep.
Sulphurated linseed oil, 1 part; oil of turpentine, 3 parts.
Oil of Turpentine (for acoustic use). Syn. Oleum terebinthinæ acousticum.
(Mr Manle.) Oil of almonds, 4 drams; oil of turpentine, 40 minims.
 Oil, Acou′stic. Syn. Ear oil; Oleum acousticum, O. terebinthinæ acousticum, L.
Prep. From oil of turpentine, 1 part; oil of almonds, 6 parts; mix. In atonic
deafness, accompanied with induration of the wax. 1 or 2 drops are poured into
the ear, or on a piece of cotton wool, which is then gently placed in it.
Oil, Black. Syn. Oleum nigrum, L. Prep. 1. Oil of turpentine, 1 pint; rape oil, 3
pints; oil of vitriol, 1⁄ 4 lb.; agitate well together with care; then add of Barbadoes
tar, 3 oz.; again agitate well, and in 10 days decant the clear portion. Linseed oil
is preferred for the above by many persons.
2. (Percivall.) Sweet oil, 1 pint; oil of turpentine, 2 oz.; mix, add gradually of
oil of vitriol; 1 1⁄ 4 oz.; again mix, and leave the bottle open until the next day.
Detersive, stimulant. Used by farriers for mange, &c.
Oil, British. Syn. Common oil of petre; Oleum Britannicum, O. petræ vulgare, L.
Prep. From oil of turpentine, 1 quart; Barbadoes tar, 1 lb.; oils of rosemary and
origanum, of each 1 oz. Stimulant. Formerly reputed to possess the most
astonishing virtues.
Oil, Camphora′ted. Liniment of camphor.
Oil, Car′ron. Liniment of lime.
Oil, Chabert’s. Syn. Chabert’s empyreumatic oil; Oleum Chaberti, O. contra
tæniam Chaberti, L. Oil of turpentine, 3 parts; Dippel’s animal oil, 1 part; mix, and
distil 3 parts. It must be preserved from the air and light. Used in tapeworm.—
Dose, 1 to 2 teaspoonfuls, in water, night and morning, until 5 or 6 fl. oz., or
more, have been taken; a cathartic being given every third day.
Oil, Exeter. Syn. Oleum Excestrense. (Gray.) Green oil, 16 lbs.; euphorbium,
mustard seed, castor, pellitory, of each 1 oz.; digest and strain. The original form
is more complex. The following is also used:—Rape oil, 1 1⁄ 2 pint; green oil, 1⁄ 2
pint; oils of wormwood, rosemary, and origanum, of each half a dram.
Oil, Fur′niture. Syn. Mahogany oil, Oil stain. Prep. 1. From refined linseed oil,
1 pint; alkanet root, 1⁄ 4 oz.; digested together in a warm place until the former is
sufficiently coloured, when it is poured off and strained.
2. Pale boiled oil, 1 pint; beeswax, 1⁄ 4 lb.; melted together, and coloured as
before. Gives a superior polish, which becomes very tough by age.
3. Linseed or boiled oil, 1 pint; Venice turpentine (pure), 6 oz.; as before.
The above are used for mahogany and other dark-coloured woods.
4. Linseed oil, 8 oz.; vinegar, 4 oz.; oil of turpentine, mucilage, rectified spirit,
of each 1⁄ 2 oz.; butter of antimony, 1⁄ 4 oz.; hydrochloric acid, 1 oz. Mix.
 5. Linseed oil, 16 oz.; black resin, 4 oz.; vinegar, 4 oz.; rectified spirit, 3 oz.;
butter of antimony, 1 oz.; spirit of salts, 2 oz.; melt the resin, add the oil, take it
off the fire, and stir in the vinegar; let it boil for a few minutes, stirring it; when
cool put it into a bottle, and add the other ingredients, shaking all together. The
last two are specially used for reviving French polish.
6. (Pale.)—a. As the preceding, omitting the alkanet.
b. From nut oil, 3⁄ 4 pint; beeswax (finest), 3 oz.; melted together.
c. To the last add of copal varnish, 3 or 4 oz.
The last three are employed for pale woods. They are all applied by means of
a rag, and are ‘polished off’ with a ‘woollen rubber’ or ‘furniture brush.’ A little
strong vinegar, or a few drops of hydrochloric acid, are sometimes added. See
Polish.
Oil, Hair. See Oil (Perfumed).
Oil and Hartshorn. Liniment of ammonia.
Oil, I′ron. Syn. Oleum ferri, O. martis, L. The old name for the liquid formed
when perchloride of iron is allowed to deliquesce by free exposure to the air. It is
excessively caustic and corrosive.
Oil, Lime. See Calcium (Chloride).
Oil, Macas′sar. See Oils (Perfumed).
Oil, Mar′row. Prep. From clarified beef marrow, 1 part; oil of almonds, 3
parts; melted together, and strained through muslin. It is usually scented with
ambergris, cassia, or mace, and slightly tinged with palm oil or annotta. Used for
the hair.
Oils, Marshall’s. Prep. From linseed oil and rape oil, of each 1 lb.; green oil
and oil of turpentine, of each 1⁄ 2 lb.; oil of origanum, 1⁄ 2 fl. oz.; oil of vitriol, 1⁄ 4
oz.; well shaken together.
Oils, Mixed. Syn. Oleum mixtum commune, L. Prep. From linseed oil and green
oil, of each 1 lb.; oil of turpentine, 1⁄ 2 lb.; Barbadoes tar and balsam of sulphur,
of each 2 oz.; oils of spike and origanum, of each 1 oz. Stimulant and rubefacient.
Used by farriers for sprains, &c. See Oils, Stamford’s (below).
Oils, Newmarket. Prep. From oils of linseed, turpentine, and St John’s
wort, of each 3 lbs.; oil of vitriol, 1 1⁄ 2 oz.; well shaken together, and the clear
portion decanted in a few days. A favourite remedy for sprains in horses.
 Oils, Nine. Syn. Old mixed oils; Oleum ex omnibus, L. Prep. From train oil, 1
gall.; oil of turpentine, 1 quart; oil of amber and oil of bricks, of each 5 oz.; oil of
spike and oil of origanum, of each 2 oz.; Barbadoes tar, 2 1⁄ 2 lbs.; oil of vitriol, 2
oz.; camphorated spirit, 1⁄ 2 pint, mixed together as the last. A favourite remedy
with provincial farriers.
Oil of Petre. See Oil, British (above).
Oil, Phos′phorated. Syn. Oleum phosphoratum, L. Prep. 1. (Ph. Bor.)
Phosphorus (dried and sliced small), 6 gr.; oil of almonds, 1 oz.; mix, place the
phial in hot water, agitate for some time, and, when cold, decant the clear oil
from the undissolved phosphorus.
2. (Magendie.) Phosphorus (sliced), 1⁄ 2 dr.; almond oil, 1 oz.; macerate in
the dark, with frequent agitation, for 14 days, then, after repose, decant the clear
portion, and aromatise it with a little essence of bergamotte.
3. (B. Ph.) Prep. Take of phosphorus and oil of almonds, of each q. s. Heat
the oil in a porcelain dish to 300° F., and keep it at this temperature for about 15
minutes, then let it cool and filter it through paper. Put 4 fluid ounces of this oil
into a stoppered bottle capable of holding four and a half fluid ounces; then add
to it 12 grains of phosphorus. Immerse the bottle in hot water until the oil has
acquired the temperature of 180° F., removing the stopper two or three times to
allow the escape of expanded air, then shake the oil and phosphorus together,
until the latter is entirely dissolved.—Dose, 5 to 10 minims.
Obs. A fl. oz. of oil dissolves rather less than 5 gr. of pure phosphorus. The
large excess ordered in the second formula must be merely for the purpose of
increasing the extent of surface acted on. It is, however, with the other
precautions given, quite unnecessary. The products of both formulæ have the
same strength.—Dose, 5 to 10 or 12 drops, in milk, barley water, or gruel, or
made into an emulsion; in chronic rheumatism, gout, &c., and as a powerful,
diffusible stimulant in various diseases with debility and general prostration of the
vital powers, &c. Externally, as a friction. It is chiefly to the presence of
phosphorus that cod-liver owes its wonderful remedial power in these affections.
Oil, Quit′ter. Prep. 1. Red precipitate, 2 dr.; aquafortis, 1 oz.; dissolve, add
of olive oil, oil of turpentine, and rectified spirit, of each 2 oz.; and agitate well
and frequently for 3 or 4 hours.
2. Ointment of nitrate of mercury (Ph. L.), 1 part; nut oil, 3 parts; melt
together, and stir until the mixture is cold. Used by farriers for quitters, &c.
Oils, Radley’s. From Barbadoes tar, 1⁄ 2 lb.; linseed oil and oil of turpentine,
of each 1⁄ 4 pint; gently warmed, and shaken together.
 Oil, Shav′ing. See Essence of soap.

Oil, Sheldrake’s. Prep. From pale boiled nut oil and copal varnish, equal
parts, melted together by the heat of hot water, and, when perfectly mixed,
placed aside in a bottle for a week to settle, after which the clear portion is
decanted. Used by artists to grind their colours in to brighten them.
Oil of Spike. 1. (Farrier’s). From oil of turpentine, 1 quart; Barbadoes tar,
1 1⁄ 2 oz.; alkanet root, 1⁄ 2 oz.; digested together for a week. Used as a
stimulating liniment by farriers.
2. (Painter’s.)—a. From rectified oil of turpentine, 3 pints; oil of lavender, 1
pint; mix.
b. Oil of turpentine (warm), 5 parts; lavender oil bottoms (genuine), 3 parts;
agitate well together, and in a fortnight decant the clear away. Used by artists and
enamellers.
Oils, Stamford’s. Syn. Lord Stamford’s mixed oils. Prep. Dissolve camphor, 1
oz., in rectified spirit of wine, 1⁄ 4 pint; add oil of origanum, 2 oz.; oil of
turpentine, 1⁄ 2 pint; green elder oil, 2 lbs.; and agitate until mixed. The rectified
spirit is now generally omitted, the camphor being dissolved in the green oil by
aid of heat before adding the other ingredients. Stimulant. Used by farriers.
Oil, Sul′phurated. Syn. Balsam of sulphur; Oleum sulphuratum, Balsamum
sulphuris, L. Prep. 1. (Ph. L. 1746.) Flowers of sulphur, 1 part; olive oil, 4 parts;
boil together in a vessel lightly covered, until they assume the consistence of a
thick balsam.
2. (Ph. L. 1824.) Olive oil, 16 fl. oz.; heat it in a sand bath, and gradually add
of washed sulphur, 2 oz.; stirring until they combine.
Prop., &c. Balsam of sulphur is a dark, reddish-brown, viscid fluid, having an
extremely disagreeable and penetrating odour, and a strong, nauseous taste. The
local action of balsam of sulphur is that of an acrid and irritant; its remote effects
those of a stimulant, expectorant, and diaphoretic. Externally, it is occasionally
used as an application to foul ulcers; and was formerly commonly employed
internally in chronic pulmonary affections, in doses of 20 to 50 drops. It is now
seldom given internally except in veterinary practice.
Oils, Three. Syn. Oleum de tribus (Van Mons), L. Oils of brick, lavender, and
turpentine, equal parts. As a stimulant liniment.
Oil of Vit′riol. Sulphuric acid.
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