RX for Readers: And on the third day

Research has shown pain after surgery is worst on day 3, echoing Torah, when angels visited Abraham 3 days after circumcision.

By
December 2, 2011 16:54
4 minute read.
Abraham visited by angels

Abraham visited by angels 521. (photo credit: Creative Commons)

My daughter had all four wisdom teeth extracted at age 21. The dental surgeon said the pain and swelling would be the strongest on the third day. It made me think about the Book of Genesis, in which angels visited Abraham the Patriarch on the third day because the pain from his circumcision peaked on that day. It made me wonder whether pain after surgery is always strongest on the third day and, if so, what the mechanism for this is.

– D.V., Jerusalem

Prof. Michael Tal, director of the Center for Research on Pain in the department of anatomy and cell and developmental biology at the Hebrew University of Jerusalem’s School of Medicine and Dentistry, and Prof. Marshall Devor, an expert in pain research in the HU Institute of Life Sciences and Center for Research on Pain, reply:

It is true that the third day following tissue damage usually constitutes the peak of suffering, and this phenomenon was noted in Genesis.

Pain from an acute trauma like tooth extraction (assuming there was no accidental nerve injury) is due to acute activation of nociceptors (sensory receptors that respond to potentially damaging stimuli by sending nerve signals to the spinal cord and brain). This should not last more than a few minutes. In addition, there is sensitization of the pain system due to inflammation. Strong analgesics given at the time of the tooth extraction block the pain during its most intense time.

Although the inflammatory process starts within hours of an operation, the accumulation of exudates – meaning swelling – takes two to three days to develop until there are changes in the skin color (red or blue) and swelling. If there is good drainage of the liquid that causes this, there will be less swelling and pain. Local anesthetics and painkillers given during and just after the surgery initially mask the pain, but these return. As the analgesic action fades, pain may intensify and therefore appear to peak at three days.

I am a 52-year-old man, and I smoked for 30 of them. Three months ago, I gave up the terrible habit because of a cough and mucus in my throat and lungs. I wonder why I’m still suffering from those symptoms; I thought they would go away when I threw away my cigarettes.

– V.M., Haifa

Dr. Yehuda Schwartz, head of the pulmonary institute at Tel Aviv Sourasky Medical Center, replies:

Your symptoms, unfortunately, are characteristic of chronic obstructive pulmonary disease (COPD). Three-quarters of all cases occur in smokers. In those who have smoked a pack of cigarettes daily for 20 years or 10 cigarettes a day for 30 years the risk of developing COPD is significant. Go to a pulmonary specialist as soon as possible for a test of your respiratory function.

If COPD is diagnosed early (stage 1), the chances of recovery are 90 percent. Early detection of COPD can be carried out with a CT scan. There is no cure, but there are medications and respiratory rehabilitation at this stage that can improve the quality of life.


There is little awareness of COPD in the general public, and it is not diagnosed enough by doctors. But after infectious diseases, COPD is becoming one of the most common diseases in the world. This is due to the smoking epidemic of decades, aging, air pollution and working in a polluted environment such as a cement factory or quarries.

Studies have shown differences in COPD rates: In Sderot, Beit She’an, Or Akiva, Ashdod, Ramle and Haifa – where you live – the rate of the disease is much higher than in Jerusalem or Tel Aviv.

Smokers (or recent ex-smokers) must be examined if they suffer from symptoms such as coughing, mucus and difficulty climbing stairs. Many times, by the time COPD shows up in symptoms, patients have already lost up to 50 percent of their respiratory function. The delay results from the fact that the lungs’ breathing capacity is larger than what is usually needed and also because the smoker believes he coughs only because of his smoking. Nonsmokers usually lose respiratory function as well, but in smokers, it occurs three times as much or more.

Unfortunately, only about a quarter of patients with moderate to severe COPD are under treatment; among the rest, many seek treatment only if their symptoms get worse. Up to a fifth of COPD patients have had lung cancer. But 75% of lung cancer patients are diagnosed with COPD when they are already at stage 3 or 4 of the disease, when the survival rate is only 15% or so, and then COPD is inoperable. Some people undergo lung transplants when organs are available and their condition allows the operation.

Not every smoker develops COPD. Genetic inheritance may offer some “protection” against developing the disease, but it’s foolish to count on it and smoke. Smokers who have a genetic defect leading to COPD will lose much faster than those without it.

Rx for Readers welcomes queries from readers about medical problems. Experts will answer those we find most interesting. Write Rx for Readers, The Jerusalem Post, POB 81, Jerusalem 91000, fax your question to Judy Siegel- Itzkovich at (02) 538-9527, or e-mail it to jsiegel@jpost.com, giving your initials, age and place of residence.


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