Reference & Education

Mumtaz Ali Tajddin S. Ali is an popular Ismaili Scholar, He has written many books on Religious Practices and Pillars, tradition and culture of Islam and Ismailism, Origin Of The Word ?Assassins? is an article taken from Encyclopedia of Ismailism.

The Nizari Ismailis were designated with a misnomer, Assassins in mediaeval Europe. This is an abusive term that had been given a wide currency by the Crusaders and their occidental chroniclers, who had first come into contact with the Syrian Ismailis in the Near East during the early decades of the 12th century. Charles E. Nowell writes in The Old Man of the Mountain that, "In the early years of the twelfth century, as the Christians spread their conquests in the holy land and Syria, they made the acquaintance of the Ismailis. Many of their historians had something to say about the sect, and what they gave was usually a mixture of information and misinformation" (cf. Speculum, 12:4, 1947, p. 503).

The Ismailis were not a band of terrorists, but their fighting against their oppressors was a struggle for survival. Mediaeval Europeans, who remained absolutely ignorant of Muslim beliefs and practices, had transmitted a number of tales, and produced a perverted image of the Ismailis. Rene Dussaud writes in Histoire et Religion des Nosaires (Paris, 1900) that, "One of the very few Europeans who have appreciated the good points of this remarkable sect and who is of opinion that the judgments pronounced by western scholars are marked by an excessive severity. It is certainly wrong to confound as do the Musulman doctors, in one common reprobation. And the Old Man of the Mountain himself was not so black as it is custom to paint him." In more recent times, too, many western scholars have continued to apply the ill-conceived term Assassins to the Nizari Ismailis without being aware of its etymology or dubious origin. Paul E. Walker makes his comments in his Abu Yaqub al-Sijistani: Intellectual Missionary (London, 1996, p. 1) that, "Until recently, however, the Ismailis were studied and judged almost exclusively on the basis of the evidence collected or fabricated by their enemies, including the bulk of the medieval Sunni heresiographers and polemicists who were hostile towards the Shi?is in general and the Ismailis among them in particular. These Sunni authors in fact treated Shi?ite interpretations of Islam as expressions of heterodoxy or even heresy. As a result, a ?black legend? was gradually developed and put into circulation in the Muslim world to discredit the Ismailis and their interpretations of Islam. The Christian Crusaders and their occidental chroniclers who remained almost completely ignorant of Islam and its internal divisions, disseminated their own myths of the Ismailis, which came to be accepted in the West as true descriptions of Ismaili teachings and practices. Modern orientalists, too, have studied the Ismailis on the basis of hostile Sunni sources and the fanciful occidental accounts of medieval times. Thus, legends and misconceptions have continued to surround the Ismailis through the twentieth century."

Benjamin of Tudela, the Spanish Rabbi of 12th century, who was the first European traveller to approach the frontiers of China (between 1159 and 1173). He is one of the early Europeans to have written about the Ismailis. He visited Syria in 562/1167, and described in his The Itinerary of Benjamin of Tudela (tr. by Marcus N. Adler, London, 1907) the Syrian Ismailis under the term of Hashishin. Next extant description is found in a diplomatic report of 570/1175 of Burchard, an envoy sent to Egypt and Syria by the Roman emperor Frederick I Barbarossa (1152-1190), in which he has used the word Heyssessini (in Roman, segnors de montana) for the Ismailis of Syria. William (1130-1185), archbishop of Tyre, is the first historian of the Crusades to have described the Ismailis of Syria in 581/1186 with the name Assissini in his History of Deeds Done Beyond the Sea (tr. by Babcock and Krey, New York, 1943, 2:390), but also admits that he does not know the origin of this name, and by no means states that it was unknown to the Muslims. The German historian, Arnold of Lubeck (d. 610/1212) used for the Ismailis of Syria the term Heissessin in his Chronica Slavorum (1869, 21:240). James of Vitry, the Bishop of Acre (from 1216 to 1228), was perhaps the best informed occidental observer of Muslim affairs after William of Tyre. He produced his Secret Societies of the Middle Ages (London, 1846), wherein he applied the term Assasini for the Syrian Ismailis. William of Rubruck (1215-1295), who had completed his visit of China in 653/1255, seems to have been amongst the first Europeans to have designated the Iranian Ismailis as Axasins and Hacsasins, hitherto used only for the Syrian Ismailis. The eminent French chronicler, Jean de Joinville (1224-1317) produced a most valuable Histoire de Saint Louis, (comp. 1305) relates the Syrian Ismaili ambassadors, who had come to see King Louis IX (1226-1270) at Acre. Joinville referred to the term Assacis for the Ismailis. Marco Polo (1254-1324) has also used the word Ashishin in his travelogue.

Different etymologies of the modern word Assassins are given in the occidental sources, such as Accini, Arsasini, Assassi, Assassini, Assessini, Assessini, Assissini, Heyssessini etc. Thomas Hyde in Veterum Persasrum Religionis Historia (Oxford, 1700, p. 493) opines that the word Assassin must be the word hassas, derived from the root hassa, meaning to kill or exterminate. This opinion was followed by Menage and Falconet. De Volney also adopted this etymology in his Voyage en Egypte et en Syrie (1:404) without citing any evidence. Historian Abul Fida (d. 732/1331) writes that Masiyaf, a town that was the headquarters of the Syrian Ismailis, is situated on a mountain, called Jabal Assikkin (Jabal al-Sikkin). The word sikkin means knife or dagger, and the name of this mountain may thus mean, the mountain of the knife. This seems to be some analogy of the coinage of the above westerners, reflecting the view in Falconet?s Memoires de l?Academie des Inscriptions (17:163); who called it, la montagne du Poigard (mountain of the dagger). Silvestre de Sacy (1758-1838) however suggests that sekkin in this case is the name of a man, so that we should translate it the Sekkin?s Mountain (la montagne de Sekkin). Michel Sabbagh of Acre suggests the origin of al-Sisani. Instead of al-Sisani, the word often used is al-Sasani means the family of Sasan. This term is used by the Arabs to indicate an adventurer. Simon Assemani (1752-1821), the professor of oriental languages in Padua, used the word Assissana in his Giornale dell? Italiana Letteratura (1806, pp. 241-262), and according to him, it is a corrupt form of Assissani in connection with the Arabic word assissath (al-sisa), meaning rock or fortress, and as such, Assissani (al-sisani) refers to one who dwells in a rocky fortress.

During the 17th and 18th centuries, the name Assassin received a good deal of attention from western scholars, who threw a flood of theories to explain its origin and significance. The mystery was finally seems to have solved by Silvestre de Sacy, who discovered that the word Assassin was Hashishiyya, i.e., the users of hashish.

The Muslims, having exhausted all their resources of condemnation, now restored to designate the Syrian Ismailis by different religious terms, such as Batiniyya and the Talimiyya. The Ismailis were also branded as malahida (or mulhidun) by their sworn enemies. Much less frequently, the Ismailis of Syria were called by other abusive term, such as Hashishiyya, i.e., the users of hashish. It seems that the oppressors had foiled in their attempt to extirpate the Ismailis and eventually made a last vehement strike upon them.

The earliest reported application of the term Hashishiyya to the Ismailis occurs in the anti-Ismaili polemical epistle issued in 517/1123 by the then Fatimid regime in Cairo on behalf of the caliph al-Amir (d. 524/1130), entitled Iqa Sawa?iqa al-irgham. This epistle contains the term Hashishiyya for the Syrian Nizari Ismailis for two times, vide pp. 27 and 32. It must be known that the well-known event of qiyamah celebrated at Alamut in 559/1164 became a main tool of the enemies of the Ismailis to discredit them. The orthodox Muslims waged a bitter propaganda, and uttered all the prevalent abusive terms for them. The dead term Hashishiyya once again was given a life, and it came to be used almost for the first time in the Seljuqid literatures. The earliest known Seljuqid chronicle is Nusratu?l Fatrah wa Usratu?l Fatrah (comp. 578/1183) by Imadudin Muhammad al-Katib Ispahani (d. 597/1201), which is now extant only in an abridged version compiled by Fateh Ali bin Muhammad al-Bundari in 623/1226, entitled Zubdatu?n Nasrah wa Nakhbatu?l Usrah (pp. 169, 195). Imadudin begins his chronicle from 485/1092, and did not put his work into its final form until 578/1183 when he had already been in Syria for 15 years. He seems first Seljuqid writer to have used the term, Hashishiyya for the Syrian Ismailis. Ibn Muyassar (d. 677/1278) simply states in his Tarikh-i Misr (p. 102) that in Syria, the Ismailis are called Hashishiyya, in Alamut; they are known as Batiniyya and Malahida; in Khorasan as Talimiyya. Abu Shama (d. 665/1267) also used Hashishiyya for the Syrian Ismailis in his Kitab al-Rawdatayn fi Akhbar al-Dawlatayn (1:240 and 258). Ibn Khaldun (d. 808/1406) writing after 13th century, mentions in Muqaddima (1:143) that the Ismailis of Syria, once called as al-Hashishiyya al-Ismailiyya, were known in his time as the Fidawiyya. All this sounds from the extant sources that the term Hashishiyya was commonly applied for the Syrian Ismailis between 11th and 12th centuries by the Muslims, and were ceased to be used since 13th century.

It is to be noted however that Juvaini and Rashiduddin do not use the term Hashishiyya for the Ismailis of Iran, as the term was not prevalent during their time in Iran. W. Madelung has however recently discovered in his Arabic Texts concerning the History of the Zaydi Imams of Tabaristan, Daylaman and Gilan (Beirut, 1987, pp. 146 & 329) that the Ismailis of Iran too were named Hashishiyya in some contemporary Zaidi sources compiled in the Arabic language at the Caspian region during the first half of the 13th century. The Zaidi Shi?ites were the closest rivals of the Ismailis in northern Iran and had prolonged military confrontations with them in the Caspian region, had launched their own anti-Ismaili literary campaign. This tends to reveal that these Arabian sources had referred to the Iranian Ismailis under the misnomer prevalent in their region for the Syrian Ismailis.

Hashish or Hashisha is the Arabic word for hemp, which is latinized cannabis sativa. Its variety is Indian hemp or Cannabis Indica, have been known and used in the Near East since ancient times as a drug with intoxicating effects. The earliest express mention of the word hashish contained in at-Tadhkirah fi?l Khilaf by Abu Ishaq ash-Shirazi (d. 476/1083). The use of hashish grew in Syria, Egypt and other Muslim countries during 12th and 13th centuries among the inferior strata of society. Numerous tracts were compiled by Muslim authors, describing that the use of hashish would effect on the users? morality and religion. Consequently, the users of hashish qualified for a inferior social and moral status, similarly to that of a mulhida, or heretic in religion. Neither the Ismailis of Syria nor the contemporary non-Ismaili Muslim texts, which were rigorous towards the Ismailis, ever attested to the use of hashish among the Nizari Ismailis.

Hashish, a narcotic drug was a common usage in the Sufic orbits in Damascus since 11th century, and they were subjected to the hatred of the theologians. Franz Rosenthal writes in The Herb: Hashish versus Medieval Muslim Society (Leiden, 1971, p. 53) that, "The use of hashish by Sufi fraternities and their presumably large role in the spread of hashish use can be accepted as a fact in view of all the later evidence pointing in this direction." The Sufi initiates were called Hashishiyya, and it was commonly known among them as Hashish al-Fuqara (the herb of the fakirs). Among them, the other titles for hashish were "digester of food" (hadim al-aqwat), "rouser of thought" (baithat al-fikr), "queen of insanity" (sultanat al-junun), "the green one" (al-akhdar), "daughter of cannabis" (ibnat al-qunbus) etc.

Nuruddin Ali bin al-Jazzar writes in his Qam al-Washin fi dhamm al-barrashin (comp. before 991/1583) that the accursed hashish "was originated by some group around the five hundreds" (ahdathaha ba"d fi"ah fi nahw qarn al-khams mi"ah). According to Franz Rosenthal, "The word fi"ah (group) is used here for the sake of the rhyme and thus may very well mean Sufis, rather than sectarians or soldiers."(Ibid. pp. 53-4) Thus, it seems possible that hashish had been discovered around 500/1106 by the wandering Sufis, who qualified the title of mulhida, or heretic in religion, and the term Hashishiyya became a common abuse in the society. Az-Zarkashi (745-794/1344-1392) in Zahr al-arish fi ahkam al-hashish and al-Ukbari (d. 690/1291) in Kitab as-Sawanih however write that it was believed that a Sufi Shaikh Hyder (d. 618/1221), the founder of Hyderi Sufi Order, discovered hashish in the province of Nishabur around the year 550/1155. This seems almost imponderable version. Franz Rosenthal writes in this context that, "The use of the drug became common among Haydar?s followers only years after his death. Therefore, the Khurasanians ascribed the introduction of the drug to him who was completely innocent of it." (Ibid. p. 45) Others also connected the introduction of hashish with a certain Sufi Ahmad as-Sawaja. In sum, hashish seems to have been discovered by the Sufis around 500/1106, but its propaganda to use and the special way of preparing it to use was introduced by the followers of Shaikh Hyder after his death. The Turkish poet, Fuzuli (885-963/1480-1556) writes in his poem, Layla Megnun (p. 167) that, "Hashish can claim to be the friend of dervishes and to be available in the corner of every mosque and among all kinds of scholars." Hashish also enjoyed particular favour in the Sufic poems, such as Ibn Kathir (13:314) quotes the following verses:-

Hashish contains the meaning of my desire.
You dear people of intelligence and understanding.
They have declared it forbidden without any justification on the basis of reason and tradition.
Declaring forbidden what is not forbidden is forbidden.

Al-Badri quotes a poem of a certain Muhammad bin Makki bin Ali bin al-Hussain al-Mashhadi, which reads:-

The use of hashish is censured by all silly persons, weak of mind, insensitive,
To the censure coming from stupid and envious individuals.
Share hashish with a goodly young man firm.
In the preservation of friendship and appointments.
Is it not a relaxation for the mind? Thus enjoy
It, all you sensible men!

Consequently, the Sufis using hashish had been rigorously condemned. Ibn ash-Shihnah (d. 815/1412) composed a couple of verses that:-

I am surprised to find a Shaikh who commands people to be pious.
But himself never heeds the Merciful One or shows piety towards Him.
He considers it permissible to eat hashish as well as usury. And (says that) he who studies truly the Sahih (Bukhari) is a heretic.

The Muslim jurists also condemned the use of hashish and demanded severe punishment, declaring it dangerous to Islam and society. Gradually, the word Hashishiyya became an abusive term mostly in Syria. One who was hated, he was branded as Hashishiyya in the society, and thus, the Syrian Ismailis were also lebelled with the same misnomer by their enemies.

Running parallel with this, it is worth keeping in mind that the Syrian Ismailis too called themselves as al-sufat (the pure, or sincere), resembling the term sufi. According to Bustan al-Jami (comp. 561/1165), the Ismailis in Syria called themselves as al-Sufat. Ibn al-Azim (d. 660/1262) however writes in his Zubdat al-Halab (comp. 641/1243) that a faction of the Syrian Ismailis at Jabal as-Summuq called themselves al-Sufat. Ismailism and Sufism are similar in their esoteric practice, but it should be known that, every Ismaili is a Sufi, but no every Sufi is an Ismaili. Ismailism is an esoteric tariqah as well as a social system with its own rules and characteristics, while Sufism is an individual concern. The Ismailis however never allowed themselves to be submerged totally into the general esoteric medley, and their form of Sufism remained quite distinctive from other mystical orders of Islam. The Ismailis were the main target of the Sunni Muslims, who used all misnomers and abusive words to discredit them. Incorporating the Ismailis with the Sufis due to their potential affinity, the Sunni Muslims and others had designated the Ismailis too with the same term. Franz Rosenthal writes, "It is worthy of note that attacks on the Ismailiyah accusing them of being hashish eaters were apparently not made very often, although this would have been an effective verbal slur." (op. cit., p. 43) Paul Johnson writes in his Civilizations of the Holy Land (London, 1979, p. 211) that, "Much nonsense has been written about this sect, which had nothing to do with hashish." Curiously enough, the term seems to have become so specific for the Syrian Ismailis that the Sufi circles using hashish had been ignored to be designated alike. After the schism of Nizari and Musta?lian, the influence of the Musta?lians in Syria was less than the Nizaris, and therefore, the Musta?lian faction also shifted this misnomer on the rival group. It is not surprising that when people cannot find the solution of a difficulty in the natural manner, they concoct a supernatural explanation, just as when they like or dislike a thing, they go to extremes, invent and contrive superstitious tales and give vent to credulous stories tinged with different misnomers.

The Musta?lian group was designated by the Nizari Ismailis in Syria as Jamat al-Amiriyya, and the latter were lebelled by the former as Jamat al-Hashishiyya as the Musta?lian group did not like that the rival group be known as Jamat al-Nizaria. Soon afterwards, the Musta?lian group disappeared almost from Syria in 524/1130, but they left behind the name Hashishiyya in their sources, and thus, it became a general usage for the Nizari Ismailis in Syria since 517/1123.

The occidental chroniclers, travellers and envoys to the Latin East borrowed the term Hashishiyya for the Ismailis of Syria, whom they pronounced as Hashishin, Heyssessini or Haisasins. Silvestre de Sacy delivered a lecture entitled Memoirs on the Dynasty of the Assassins and the origin of their Name on May 19, 1809 in the Institute of France, which was a landmark in the relative study. In addition to the few oriental sources published or referred by previous scholars, de Sacy was able to draw on the rich Paris collection of Arabic manuscripts, and states that, "Nor should there be any doubt, in my opinion, that the word hashishi, plural hashishin, is the origin of the corruption heissessini, assassini, and assissini. It should not surprise us that the Arabic shin was transcribed by all our writers who used the Latin language by an s, and in the Greek historians by a sigma. They had no choice. It should, moreover be observed that the shin is pronounced less strongly than ch in French. What can rightly be asked is the reason why the Ismailis or Batinis were called Hashishis."

After picking up the word Hashishiyya for the Syrian Ismailis, the Crusaders attested further fabrications. The daring behavior of the Ismaili fidais, who usually carried their mission - a struggle for survival, had exceedingly impressed the Crusaders, who would rarely endanger their own lives for other than worldly rewards. The Crusaders failed to compete with the valour of the Ismaili fidais, therefore, they propagated that they were using hashish before fighting, but they forgot to understand that the drunkenness caused by hashish merely consists of a kind of quiet ecstasy, rather than a vehemence apt to fire the courage to undertake and carry out daring and dangerous missions. Franz Rosenthal writes in The Herb: Hashish versus Medieval Muslim Society (Leiden, 1971, pp. 42-3) that, "It has been pointed out that hashish does not have the properties that would ordinarily make it a serviceable stimulant for anyone being sent on a dangerous mission of assassination." The editors of Encyclopaedia Britannica (New York, 1978, p. 94) write that, "Stories of the terrorists? use of hashish before setting out to commit murder and face martyrdom are doubtful." Neal Robinson writes in Islam ? A Concise Introduction (Surrey, 1999, p. 169) that, ?Although there is no evidence that the Nizaris used narcotics, their Sunni opponents gave them the abusive nickname, Hashishiyyin (hashish users), which passed into English as Assassins.? Bosworth also writes in The Islamic Dynasties (cf. Islamic Survey, series no. 5, Edinburgh, 1967, p. 128) that, "The story related by Marco Polo and others, that hallucinatory drugs were used to stimulate the assassins to bolder efforts is unconfirmed in any of the genuine Ismaili sources." The Muslim authors, unlike the western authors, did not fantasize about the real spirit of sacrifice of the fidais in defending their faith around aggressive milieu. Instead of knowing their struggle, they branded them with the then prevalent abusive term, Hashishiyya. Hence, the misnomer Hashishiyya, picked up by the Crusaders in the beginning of the second half of the 12th century, mainly through oral channels, came to be pronounced as Hashishin, Heyssessini or Haisasins. It further underwent corruptions, and evolved as Axasin, Accini, Assassini, Assacis, Ashishin, Assassini, and finally resulted the modern genesis of the English word, Assassin. It later was coloured by spurious and extravagant fables, smacking exaggeration in western popular lore and literature.

It deserves notice, however, that Henry, Count of Champagne (d. 593/1197) had visited the Syrian Ismaili territories in 590/1194, where he had personally alleged to have witnessed the falling down of the two Ismaili fidais from a lofty turret upon the signal of the Ismaili leader to demonstrate an example of obedience. This event became famous in the occidental sources bluntly by the end of 13th century without perception of the spirit of sacrifice of the fidais. Thus, in the West, the Ismailis have been the subjects of several hotchpotch of legends, and were portrayed in different terms, so as to designate them ultimately as Assassins.

1. INCREASED INTRACRNIAL PRESSURE
?Brain swelling with edema and blood collects within the brain.?

2. ANATOMY AND PHYSIOLOGY OF BRAIN:
* Brain the most critical organ of human body.
* Protected through three protective structures;
A. Skull-bony structure
B. Meningies-Dura, Arachnoid, Piamatter
C. Cerebrospinal Fluid.

3. PHYSIOLOGY OF INTRACRANIAL PRESSURE:
Intracranial pressure is normal at 4-15mmhg and 50-300mmof water. Skull is not flexible structure. If pressure of any of the above three will increase compensatory decrease in other two. If exceed the compensatory efforts increased intracranial pressure.

A. CEREBRAL BLOOD FLOW;
Brain injury can result from brain stem compression and reduction in cerebral blood flow.
Ohm?s law
CBF = (CAP-JVP) \ CVR
CAP=CAROTID ARTERIAL PRESSURE
JVP= JUGLARVENOUS PRESSURE
CVR= CEREBROVASCULAR RESISTANCE

B. CEREBRAL PERFUSION PRESSURE;
A clinical surrogate for the adequacy of cerebral perfusion. CPP is defined as mean arterial pressure (MAP) minus ICP
CPP= MAP-ICP.

4. PATHOPHSIOLOGY:
Oedematous brain tissues lead to inflammation\hematoma formation
o increase pressure in the cranial cavity
o compensatory decrease in cerebral blood flow
o cerebral blood flow
o cerebral hypoxia
o ischemia of vasomotor centre
o CUSHING?S sign (increase B.P, decrease pulse) - late sign of increased intracranial pressure suggest irreversible brain damage.

5. CAUSES:
a. Mass lesion abscesses
b. Extadural hematoma
c. Subdural Hematoma
d. Subacutesubdural intracerebral hemorrhage
e. Stroke
f. Hepatic encephalopathy.
g. Brain Herniation
h. Seizures.

6. CLINICAL MANIFASTATION;
? a. Severe Headache (e.g. head trauma, subarachnoid Hemorrhage)
? b. Confusion or Diminished responsiveness
? c. Hemiparesis
? d. Seizers
? e. Spontaneous periorbital bruising
? f. Bradycardia
? g. Respiratory Depression
? h. Contra lateral papillary dilation
? i. Loss of gag reflex
? j. Glass cow coma scalelessthen or equals to 8
? k. Temperature may rise
? l. Cushing triad: increased systolic blood pressure, widened pulse pressure and slow heart rate.
? m. Decorticate or decelerating posturing.
? n. Occasional transient elevation associate with Sneezing, Cough,

DIAGNOSTIC FINDINGS

7. ROLE OF COMPUTED TOMGRAPHY:
CT scan may suggest elevated ICP based on the presence of mass lesion, midline shift. Since ICP monitoring is also associated with a small risk of serious complication that is CNS infection, intra cranial hemorrhage.

8. TYPES OF MONITORS
A. INTRVENTRICULAR;
Intraventricular monitors are considered the ?gold standard? of icp monitoring catheters. They are surgically placed into the ventricular system and a fixed into the drainage bag and pressure transducer with a three way stopcock .It allow the treatment of some elevated ICP via drainage of csf.

B. INTRAPARENCHYMAL;
Consist of a thin cable with an electronic or fiber optic transducer at the tip. The most widely used device is the fiber optic Camino system. These monitors can be inserted directly into the brain parenchyma via a small hole drilled in the skull. It cause ease of placement and lower the risk of infection.

C. SUBARACHNOID;
Subarachnoid bolts are fluid coupled systems within a hollow screw that can be placed through the skull adjacent to the dura. The dura is then punctured, which allows the CSF to communicate with the fluid column and transducer. The most commonly used subarachnoid monitor is the Richmond bolt. It has low risk of infection and hemorrhage.

D. TRANSCRANIAL DOPPLER:
Measures the velocity of blood flow with in the proximal cerebral circulation. TCD can be used to estimate ICP based on characteristic changes in waveforms that occur in response to increased resistance to cerebral blood flow. TCD is poor predictor of ICP, although in trauma patients. TCD finding may correlate with outcome at six months.

9. GENERAL MANAGEMENT:
Evacuation of a blood clot
Resection of a tumor
CSF diversion in the management of hydrocephalus
Treatment of underlying me
Metabolic disorder

10. SYMPTOMATIC TREATEMENT:
a. SEDATION AND BLOOD PRESSURE CONTROLING:
Keeping the patients appropriately sedated can decrease ICP by reducing metabolic demand, venous congestion and the sympathetic responses of hypertension and tachycardia.

b. POSITIONING:
Patient with elevated ICP should be positioned to maximize venous out floe from the head. Important maneuver including excessive flexion or rotation of the neck avoiding restrictive neck taping, minimizing stimuli that could induce valsalva responses, such as end tracheal suctioning. Keep head elevated above the heart level at 30 degree to increase venous outflow

c. FEVER:
Elevated metabolic demand in the brain results in increase cerebral blood flow and can elevate ICP by increasing the volume of blood in the cranial vault .Conversely; decreasing metabolic demand can lower ICP by reducing blood flow. Fever increase brain metabolism, and has been demonstrated to increase the brain injury in animal model. Aggressive treatment for fever includes acetaminophen and cooling.

d. HYPERVETILATION:
Use of mechanical ventilation to lower paco2 to 26 to 30 mmhg has been shown to rapidly reduce ICP through vasoconstriction and a decrease in the volume of intracranial blood

e. THERAPEUTIC HYPOTHERMIA:
Hypothermia decrease cerebral metabolism and may reduce ICP and cerebral Blood flow.

11. PHARMACOLOGICAL TREATEMENT:
a. ANTIEPILEPTIC THERAPY:
Seizures can both complicate and contribute to ICP Anti convulsant therapy with EEG done

b. MANNITOL:
It reduces brain volume by drawing free water out of the tissues and into circulation, where it exerted from the Kidney.

c. BARBITURATES:
The use of barbiturate s is predicated on their ability to reduce brain metabolism and cerebral blood flow, thus lowering ICP and exerting a neuroprotective effect.

12. SURGICAL TREATEMENT:
a. REMOVAL OF CEREBROSPINAL FLUID:
When hydrocephalus is identified, a ventriculostomy should be inserted, Slow removal can also be accomplished by passive gravitational drainage through the ventriculosomy.

b. DECOMPRESSIVE CRANICTOMY;
Decompresive cranictomy removes the rigid confines of the bony skull, increasing the potential volume of the intracranial content, cranictomy alone lowered ICP 15 PERCENT, but opening of the bony skull resulted in an average decrease in ICP of 70 percent.

13. NURSING DIAGNOSIS AND INTERVENTIONS:
a. NURSING DIAGNOSIS
Ineffective breathing pattern and ventilation related to hypoxia.

a. NURSING INTERVENTION:
? Reassure person that measures are being taken to ensure safety.
? Distract person from thinking about anxious state by having him or her maintain eye contact with you; say, ?Now look at me breathe slowly with me like this?.
? Explain that one can learn to overcome hyperventilation through conscious control of breathing.
? Discuss possible causes, physical and emotional and methods of coping effectively.
b. NURSING DIAGONSIS:
Altered Nutrition less than body requirement related to metabolic changes and inadequate intake.

NURSING INTERVENTION:
? Determine daily caloric requirements that are realistic and adequate. Consult with dietitian.
? Weight daily, Monitor laboratory results.
? Explain the importance of adequate nutrition. Negotiate with client intake goals for each meal.
? Plan care so that unpleasant or painful procedures do not take place before meals.
? Provide pleasant, relaxed atmosphere for eat in (no bedpans insight).
? Arrange plan of care to decrease or eliminate nauseatic odors.
? Maintain good oral hygiene.
? Try commercial supplement available in many forms (liquid, powder, pudding).
? Establish intake goals with client, physician and nutritionist.

c. NURSING DIAGNOSIS:
Altered temperature related to damage to temperature regulating mechanism.

NURSING INTERVENTION:
? Teach the person the importance of adequate intake (> or = 20,000ml per day unless contraindicated by heart or kidney disease)
? Monitor intake and output.
? Assess whether the clothing or bed covers are too warm for the environment.
? Teach the importance of increasing fluid intake during warm weather and exercise.
? Explain the need to wear loose fitting clothing.
? Teach the early sign of hyperthermia or heat stroke.
? Flushed skin.
? Headache
? Fatigue
? Loss of appetite.

d. NURSING DIAGNOSIS:
Potential for impaired skin integrity related to bed rest and hemi paresis.

NURSING INTERVENTION:
? Assess the integrity of skin.
? Identify the stage of pressure ulcer development
? Assess the status of ulcer: size, depth, edges, undermining.
? Assess necrotic tissues, type, (color, consistency, adherence) and amount.
? Wash reddened area gently with a mild soap rinse thoroughly to remove soap and pat dry.
? Gently massage healthy skin around the affected area to stimulate circulation.
? Increase protein and carbohydrate intake to maintain a positive nitrogen balance.
? Weight the person daily.
? Determine serum albumin level weekly to monitor status.

e. NURSING DIAGNOSIS:
Altered thought processes (deficit in intellectual function, communications) related to brain injury.

NURSING INTERVENTION:
? Explain attitude about confusion (in self, caregivers, significant others) Provide education to family, significant others and caregiver regarding the situation and method of coping.
? Maintain standard of empathic, respectful care.
? Encourage significant others and care givers to speak slowly either low pitch and at an average volume.
? Provide respect and promote sharing
? Pay attention to what person is saying.
? Pick out meaningful comments and continue talking.
? Call person by name and introduce your self each time.
? Use name the person is prefers, avoid ?pops? or ?moms?
? Convey to person that you are concerned (through smile and unhurried pace).
? Use memory aid if appropriate.
For communication
? Use pad, pencil, alphabets, letters hand signals, eye link head nodes and bell signals.
? Make flash cards with pictures or words depiciting frequently used phrases (Move my foot, glass of water).
? Use normal loudness level, speak unhurriedly in short phrases.
? Encourage person to take plenty of time talking and to enunciate word carefully with good lip movement.
? Delay conversation when the person is tired.

f. NURSING DIAGNOSIS:
Impaired physical mobility related to increased intracranial pressure.

NURSING INTERVENTION:
? Perform passive ROM exercise on affected limbs.
? Support the extremity above and below the joint.
? Use a footdrop.
? Avoid a prolong period of sitting or lying in the same position.
? Change the position of the shoulder joints every 2 to 4 hours.
? Use a small pillow when in fowler?s position.
? Support the hands and wrist in natural alignment.
? If the client is supine or prone, place a rolled towel or a small pillow under the lumbar curative or under the end of the rib cag.
? If the client is in the lateral position, place pillow to support the leg from groin to foot and a pillow to flex the shoulder and elbow slightly; if needed, support the lower foot in dorsal flexion with a standing.
? Use hand and wrist splints.

14. TEACHINGS:
o Back Care
o Hand and foot care
o Suctioning
o Medications
o Diet
o Deep breathing exercise

15. REHABILITATION THERAPY:
o Speech therapy
o Continuous GCS monitoring
o Memory orientation and repetition
o Swallowing therapy
o Use of assistive devices range of motion and walking
o Continues lab monitoring, aggressive chest physiotherapy
o Family teaching sessions

Zainab Ramzan Ali Surgical Ward Nurse RN (Registered Nurse) from AKUSON, She has written on a range of Intracrnial Pressure related issues such as Anatomy And Physiology Of Brain, Physiology Of Intracranial Pressure.

Introduction to the IELTS test

The International English Language Testing System (IELTS) is a test of English language proficiency, developed by the University of Cambridge Local Examinations Syndicate. Today IELTS is accepted as evidence of a prospective student?s level of English by most universities in English speaking countries.

There are two different IELTS tests that you can do: Academic and General. But this test is usually taken for university admissions. IELTS is not just a test that you can pass or fail. Your English proficiency skills are reported according to a scale from bands one to nine.

Tests and tasks conducted have been designed keeping in view the general interests of the educated people, so the person taking the test needs not to do any specialist courses. The test contains four parts - Reading, Writing, Listening, and Speaking.

The reading component of the IELTS test
The IELTS reading test duration is one hour. During this time the candidate has to read three texts of between 500 and 900 words each. The texts and questions increase in difficulty. He has to answer 40 questions within the time limit of 60 minutes. Most students find it difficult to complete the whole paper, so it is important for candidates to be completely prepared for all the tests.

The writing component of the IELTS test
The IELTS writing test takes one hour. During this one hour the candidate has to complete two tasks.
? TASK ONE: Task one is a report based on some graphic information provided on the question paper. The graphic information will come in one of five forms. The candidate is required to describe the information in 15 words. Task One should be completed in 20 minutes. It is important that the candidate is familiar with the language to produce a strong report.
? TASK TWO: The next task is an essay based on a topic given on the question paper. The candidate should write at least 250 words in 40 minutes.

It is recommended that the candidate should follow the advised time limits as Task Two carries more Band weight than Task One. Remember that unreadable handwriting will cost the final score.

The listening component of the IELTS test
The IELTS listening test takes approximately 30 minutes.
The listening material is recorded on a cassette tape which the candidate will hear only once. The test is divided into four sections in order of increasing difficulty. First two sections are based on general interest such as a report of a bank robbery or a speech from a politician. Section one will be a dialogue and section two will be a monologue.

Sections three and four will have an education focus. There will be a lecture and a discussion between two to four people.
As the candidate listens he should write his answers on the question booklet. At the end of the recorded material he will be given ten minutes to copy his answers onto the fresh answer sheet.

The candidate should be well prepared for the listening test as many people don?t feel confident of giving a smooth test.

The speaking component of the IELTS test
The IELTS speaking test takes between 11 and 14 minutes and is in the form of an oral interview between the candidate and an examiner.
During the interview the candidate has to answer the questions asked by the interviewer.

The interview consists of:
? Some general questions about yourself, your life and your interests
? A short talk on a particular topic
? A discussion of issues

It is strongly recommended that the candidate should relax and speak as confidently as he can because candidates losing their confidence in this test can affect their band scores.

Ibrahim Machiwala (Lodhi) is a regular contributor to ehealthguide.info - a highly informative and authoritative website specializing in Online Education, also features information on E-Commerce and Stock Exchanges such as Nasdaq Stocks.