THE AMBASSADORS

SELECTED STUDIES

Volume 1, Issue 1

July 1998

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Prof. M.K. Booz is an international orthopedic surgeon with an extensive experience in Egypt, Kuwait, Saudi Arabia, Afghanistan, and the United Kingdom. His study "Endemic Orthopedic diseases in Bedouins" has been selected for publication in the book entitled "THE INBRED AND OUTBRED POPULATIONS". The book will includes a biomedical and psycho-sociocultural analysis of the world's populations.

 

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Photographed by Dr. Sayed Nasser in 1973.  

Dr. Booz, Dr. M. El--Moheiny (Syria), Dr. O. Dabbour (Palestine) and Dr. Farag (Egypt) in Jahra Area (>85% Bedouins).

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THE BEDOUINS

The Desert Nomads

Councilor Pan-Arab Orthopedic Association

 

This chapter deals with endemic diseases of Bedouins. During my work in Kuwait for thirty years (1960-1990), I came across certain ailments, almost confined to the Bedouin community at that time.

Bedouin, in English, refers to 'Bedu' in the Arabic language. He is the nomad in the desert, rears camels, sheep, goats and migrates extensively, looking for water and vegetation to feed his animals. A completely independent person, who does not live under international borders, crossing state boundaries, and settle anywhere suitable for his herd. His standard shelter is a tent, which he and his household weave from goats hair. With the first rain shower, the hairs swell, rendering the tent waterproof! Their tents are easy to put-up and equally to dismantle and carry on camels' backs.

Bedouins do not settle in one location, so they elect to have no houses and do not grow trees. Although always on the move, those who have to change their lifestyle, usually due to poverty, make very good farmers, skilled workers, soldiers and policemen. With the governments drive to make use of their Bedouin population, whom they like and trust, schools and hospitals attract the young, and nowadays there are a good number of doctors, engineers, teachers and, of course officers. Their code of ethics is very high, definitely superior to that of city dwellers, they are courageous people, honest, generous, and above all, have a code of honor (Sharaf), which he defends with his life. Those qualities appeal strongly to rulers, who prefer them to expatriates.

Bedouins are present in all Arab countries, at the outskirts of fertile land, but in greater numbers in the Arab Peninsula, including Sinai, Jordan, Syria and Iraq. Alan Keohane (1994) estimated their number in the Arab world at around five million. Their number is declining and only ten percent or so of them live the traditional Bedouin lifestyle. Two million are in Saudi Arabia, and 300,000 in Syria. Genetic disorders among the Bedouins has been critically discussed recently (Farag and Teebi, 1997). This study focuses on non-genetic orthopedic disorders.

Madura foot affects people who walk bare footed, hence Bedouins are prone to catch the disease. All our patients came from the desert (Booz et al, 1977). Bones and joints of the extremities are sometimes involved in the deep mycotic infections of the skin and subcutaneous tissues, characterized by swelling, suppuration, multiple sinuses, sinus tracks and the presence of "granules" in the pus. Granules are actually colonies of the etiologic fungus, colorless, yellow, brown or black, according to the causative organism.

Because of localization and slow spread, life expectancy is good. The disease, however, may incapacitate the patient and in some patients, treatment short of amputation is unsatisfactory. The fungi causing madura mycosis are usually resistant to medical treatment including the antimycotic antibiotics.

The causative pathogens are inoculated by thorns contaminated with putrefied material or other polluted debris. Once in the soft tissues of the foot, the pathologic fungi multiply slowly and relentlessly, causing multiple abscesses, destruction, osteomyelitis, sinuses and discharge.

Hydatid disease is not uncommon in Kuwait. In the slaughter house, cysts are commonly found in the lungs and liver of sheep, cows, goats and camels. The camels are heavily infested. This disease is caused by the cystode worm echinococcus granulosus which inhabits the small intestine of the dog. Its ova coming out with the stools, infect cattle or humans, giving rise to hydatid cysts. El-Gazzar and McCready (1962) and Alldred and Nisbet (1964) gave an account on the parasitology and prevention of the disease. The incidence of the disease in bone is low compared with other organs of the body.

Reports from different parts of the world differ slightly. In South America, the incidence of hydatid disease in bone is 2% of all forms of hydatid disease in all organs of the body (Ivanisavich, 1934). In Australasia, it is less than 1% (Aldred and Nisbet, 1964) and is 4% in Kuwait (El-Gazzar, 1962).

The presentation of every case is different from the others. The diagnosis of this rare disease is difficult and is often missed. I came across 15 cases of hydatid disease of bone, and had the opportunity to manage most of them. Humerus, femur, tibia, fibula, knee joint, spine, pelvis, and ribs where the bones encountered.

The prevention of hydatid disease in humans depends on their ability to keep of the gut of the dog free from the cestode worm,echinococcus granulosa. The sheep eaten in rural and desert areas are usually slaughtered privately, far from the control of health inspectors. Furthermore, there is no control on the excreta of dogs, cats and other domestic animals. This explains why most of our patients are Bedouins.

Prevention of hydatid disease in sheep, cattle, and camels should go hand in hand with control of the disease in dogs. The worms inhabit the small intestines of the dog, and the ova in the dog's excreta infect cattle, sheep, camels, or humans. To break this cycle in Bulgaria, all infected cattle are killed (Karaguiosov, 1970). The problem is more complicated in vast desert areas with their uncontrollable population of Bedouins, where municipal laws do not exist.

 

Tuberculosis of Bones and Joints

Tuberculosis is at present a rare disease in Europe and North America but is still a major problem in the Middle East. Being a prosperous country, Kuwait invites many foreigners who bring with them a variety of diseases such as tuberculosis, hydatid, and Bilharsiasis. Bedouins coming in and out of the state, catch the disease. According to the tuberculosis control center report (1971), the total number of new cases was 930 patients in the year 1971, 7.4% of them were of skeletal lesions. A successful effort is being made to combat the disease by preventive measures and the number is declining despite of the increase in population size. In 1988, the new cases came down to 480 patients, while the population rose to 1,958,477 (Abdel-Aty M. & Abdel-Ghany K., personal communication).

Cauterization is the method of treatment by these tribal medicine men and women. Bedouins usually seek advice when the disease is advanced, when tribal medicine fails. We prefer to treat Bedouins by surgery whenever possible. It confirms diagnosis, hastens cure, since followup at home is difficult and sometimes impossible. The results of modern treatment of bone and joint tuberculosis depends on early diagnosis based on microscopic sections, culture, and animal inoculation (Waring, 1971).

 

Associated Urinary Tuberculosis

It is now generally accepted that genitourinary tuberculosis is sequel of tuberculosis bacillaemia. As would be expected, the disease is often associated with other tuberculosis foci of undoubted hematogenous origin, such as milairy disease and skeletal tuberculosis (Ried, 1957). Snellman (1950) examined the urine of 373 patients of skeletal tuberculosis and found bacilluria in 15.3%, the majority having no evidence of frank renal tuberculosis. Harris and Coulthard (1942) found that 23.3% of 296 skeletal tuberculosis patients had tuberculosis lesions of the genitourinary tract. Wilkinson (1950) examined 197 adult and 83 children with skeletal tuberculosis. He found genitourinary tuberculosis in 19% of adults and in 1 child. Booz and Gayyar (1967) did not find a single case of genitourinary tuberculosis in 216 patients with skeletal tuberculosis in Kuwait.

 

Fractures and dislocations

Bedouins manage simple fractures satisfactorily. They know about splints, locally prepared from palm tree leaves, wood, tree branches, goat skin, leather, and ropes. Sometimes they plaster the fractured limb by a paste prepared from flour, eggs and salt. This craft is passed from father to son, and being ignorant and illiterate, can sometimes be very dangerous. Ropes around the rope splints, when tight may lead to swellings and even gangrene. I came across such complications as well as ulcers and nerve paralysis, leading to dropped wrist or dropped foot. They usually keep the splint for three weeks in a child and one month in an adult. The food they recommend is milk, meat and dried dates (they call "tamr"). This diet is obviously rich in proteins, minerals and vitamins.

Cautery is another method, and a popular one, in treating obstinate strains, aches, joint pains, and sciatica. Many patients claim cure, but again this is not without danger. In the case of sciatica, the Bedouin quack picks three of four points along the lower limb. One on the 1st sacral spine, the 2nd mid thigh, the 3rd on the neck of the fibula, where the lateral popliteal nerve is superficial, and the 4th at the root of the little toe. The Cautery on the neck of the fibula often ends with a dropped foot. Cautery is performed with obvious skill, without anesthesia, using rods of red-hot iron.

Eleven centuries ago, Albucasis used many tools in different shapes and of different metals, sometimes silver (Spink & Lewis, 1973). Avicenna used gold (Iskander, 1967). The procedures are described in detail in the original books written in the 8th and 9th centuries, showing drawings of those Cautery tools, including one to use in treating recurrent dislocation of the shoulder and describing the method. Of course this was nothing to do with what Bedouins practice today.

 

References

Aldred, A.J. & N.W. Nisbet (1964): Hydatid Disease of Bone in Australasia. J. Bone Joint Surg., 46B: 260.

Booz, M.K. & AR El-Gayyar (1967): Urogenital tuberculosis in Kuwait in association with skeletal tuberculosis. J. Kwt. Med. Assoc., 1: 92.

Booz, M.K. & H.T. Waly (1972): Surgical treatment of tuberculosis of bones and joints in Kuwait. J. Kwt. Med. Assoc., 6: 75.

Booz, M.K. & H.T. Waly (1975): Tuberculosis of bones and joints. J. Kwt. Med. Assoc.

Booz, M.K., M.M. Salim & M. Tamami (1977): Fungus infection of bones and joints of lower extremity in Kuwait. J. Kwt. Med. Assoc., 2: 69.

El-Gazzar, A. & D.W.A. McCready (1962): Hydatid Disease in Kuwait. Brit. Med. J., 2: 232.

Farag, T.I. & Teebi A.S. (1997). Genetic Disorders Among Bedouins In " Genetic Disorders Among Arab Populations " Eds.: AS Teebi and TI Farag. Oxford Univ. Press, NY.

Iskander, A.Z. (1967): A catalogue of Arabic manuscripts on medicine and science. London: The Wellcome Historical Medical Library.

Karaguiosov, L. (1970): Personal Communication

Keohane, Alan (1994): Nomads of the Desert. Kyle Cathie Ltd.

Snellman, B. (1950): Occurrence of tuberculosis of renal parenchyma in association with bone and joint tuberculosis. J. Acta. Chirg. Scand. C., 100: 259.

Spink, M.S. & G.L. Lewis (1973): Albucasis on surgery and instruments. London: The Wellcome Institute of the History of Medicine.

Waring, T.L. (1971): Campbell's operative orthopedics. St. Louis: The C.V. Mosby Company.

 

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