Puerperal breast abscess

PUERPERAL

BREAST

ABSCESS” (:.

C)rrs

SMITH,

ALEXANIJER

(From College

the Departments of Medicine,

of Obstetrics, Cook County University of Illinois, Chicago)

VARGA,

Hospital,

M.D., OAK M.D.,

PARK,

ILL.,

ANI)

PITTSI<~.RGH,

and of Obstetrics

PA.

and Gynecology.

T

HE occurrence of puerperal breast infection has been reported at times, when seemingly there was a sudden outbreak or concentrated increase in the number of cases. Alany authors, inclutling Sherman1 recent,ly, C’olbeck’ in 1949, Knott and Blaiklcy” and Hobbs’ in 1944, approached the subject from this aspect. The latter three ma(lc comparable statements that it, was the impression of many obstetricians that outbreaks of breast abscesshad become more frequent in recent years. That, was in 1944, but despite the advent and liberal use of many antibiotics, the gravity of t,he situation has not lessened; if anyt,hing, it has become more serious. In ;I IO-year study of t,his problem we have found that although there arc minor Huctnations when the ineidenct: is higher than usual, there has been a rclati\-cly steady maintenance of t,his disease, cscept for the past 2 years when a market1 increase has been noted. In County Hospital practice, the lyp~ of patient, with her attendant economic status and social environment, has not alt,ered; therefore, other factors must bu evalnahcd. Contamination by hospital personnel has been regarded as a potent source of infcctiou. The dcvclopment of new or mutant strains of bacteria t,o which the patient ha.s not acquired natural rcsistamx, which are not sensitive t,o antibiot,ics, or al’c not controlled by modern aseptic techniques, has been demonstrated by numerous investigators. Jt is I)robably within this realm that the solution t,o the, pr~o1~lcw1 lies. On csamining Fig. 1 and compa,rin,0. the entls of the scale, .ycars 1945 and 1.955, it is seen that although the clclivc~ries have increased approximately three and one-half Cmes, the number o t’ absccssc~s has increased approsirt~at~cl~ tight and one-ha11’times. ‘In view of t,hc shortage in hospital beds and spacr. O?l(' might interprclt, this to indicatt: that, o\-ercrowding and less cfficicnt nianagetncnt as a ~o~~scc~~w~~cc wonlcl in l)art, account for the increase in it-rfcct,ion. At the Phila~tl(~lphia C:enel*al Hospital ’ 1he annual delivery ratr of approsimatcbly 4,000 per ~T~I~LIIU has not mat,erially changed since 1950, yt,t tht’) have experiencecl an upward surge in the number of breast abscesses,approsirnatcly thresh and one-half tilncs as n~any occurring in 1955 as in 1950. Tn OUI' series, hospital c~ontalninat,iotl does non S(YJIIIt,o 1)~ the main or only souwc of infection, as suggested by other authors. I t1 comparison with the Philadelphia C:cneral Hospital, cswl~t 1’01. the yeal* 1!)55. our annual incidence of puerperal abscessis dccidctlly lowl-cr. *Presented

at

a meeting

of

the

Chicago

C:ynecological

1330

Society.

Jan.

18,

195i.

PUERPERAL

BREAST

ABSCESS

1331

Until 1954, there were small numbers of casesnoted which were relatively evenly dispersed throughout the various months. $ncc then, when greater numbers of cases have been encountered, June, July, August, September, and October seem to be the peak months of the year, particularly in 1955. The appearxncc of cases has been more or lrss continuous, and periodic outbursts as rcportcd by other authors”, 8-i (lid not occur in our series. Of late, there seemsto 1~ no particular month when the disca,scis not present in significant nuIlllxm.

Material This study is based on 147 cases of breast abscess at the Cook County Hospit,al from June I, 1955, through Dec. 31, 3955, in which bacteriologic cultures, m&hods of treatment, and follow-up are described and discussed. (‘ont,rol c,ultures were taken from the nipple and areola of patients admittctl to the labor rooms and were repcatctl on the same patients on thtb day of discharge, in order to determine whcthcr pathogenic bacteria notma1l.y inhabit the b1*caast 01.if they are acquired possibly by hospital contact. There were a tot,al of 159 xlmissions. reprcscnting 1” rc~admissiortsfor further therapy. Fifty-seven, 38 per cent, w’cre primiparas. Krcast manipulation occurred as follows: 111 nursed, 17 nursctl and also utilizthtl a l)ycast pump, 16 only pumped the breasts, ant1 1:lmticnts dcnicd either ~)rocc~lure. 1945-'56 100

COOK

COUNTY

HOSPITAL,

CHICAGO [ 2.0 %

1

-----

Monfhly Yearly

incidence incidence

1.5

70 60 I.0

50 40 30

0 .5

20 10

0 I& B’ig.

I.-Per

cent

of

total

2 3 4 5 6 7 0 9 10 11 '46 '47 48 '49 '50 '51 '52 '53 '54 '55

deliveries

resulting

in

breast

abscess

on

12O MONTH5 YEARLY a monthly

and

yearly

basis.

Symptoms and Lesions In the majority of cases, 104, or 70.7 per cent, the onset of symptoms occurred between the elevent,h and thirtieth days. In 30 cases the onset was prior t,o the eleventh day, in 7 cases between the thirtieth and fortieth days, and in 4 casesbeyond 40 days. The shortest period was 2 days am1 the longest, 12:3days. The duration of symptoms prior to admission probably constitutes an important factor in the extent of the lesion in individual cases. In the majority, involvement included at least a quarter segment of the breast, both glandular and connective tissue, while in more s~~vcrecases practically the whole breast

01’ stagnation and infection is at the time of weaning, but it may Occur at any time when there is interference with the proper cmpt>-ing of the loaded breast. Newton and Newton15a lc and Wallerl’ wrote extensively and thoroughly on the I&-clown reflcs, a mechanism by which the mother a&rely expels the milk which ThelT pointed is already in the breast in response to t,hc stimulation of sucking. out that the rcflcs is c5ti*c~mcl~- sensitive to emotional stimuli and can hc‘inhihitcd b\- l)ain, emotional upheaval, or fear.l”. ‘: In order to avoid stagnation due to impropor functioning of this rcflcs, it srems wise not to allow or encourage breast feeding in pz tients who dislikr, or n-ho arc indifferent or averse to, thr proccdurc. (hl thcx other hand, in PiltiMtS desirous of nursing, it is cssent.ial to help tli6m a\-oitl discomfort, cml)ari~asslllcnt, emotional distnrbanccs, and distract,ions both in tliv hospital and at homc~.

Bacteriology A total of 99 breast abscttss cultures wcrc obtained in different patients, 111(1t.casults of which al*c shown in Tal>l(~ 1. Of thvsc. 96 u’(~I’c pure cultures and only- 3 wcro mixed cultures. Of the pui’c’ eultuf’cs, 59 were hcmolyt.ie Stnph~flo(‘0rr’tL.s f!wc~s, roagulase positivca, 36 were nonlicmolyt~ic Stn@2/lococczis QICI‘CI~.S, voagnlase positive, and I was nonhemolytic 8tophylocouus (117ms, coagulasc positivcx. Thcl mixed cultllrcs consisted of :

Purr

cwltures

It is seen that thcsc organisms J~OSSCSS pathogenicity as indicated by the ability to hcmolq-z;cblood or to coagnlat,e plasma,1Sand all of the staphylococcal organisms posscssrtl onv or t.hc other of these factors or both. Apparently, pathogcniv staphylococci arc the prime offenders, being found in all cultures with strcptocaocvi and coliform type organisms associated in only the 3 mixctl enlturcs. 121)scess attributable primarily to other hattcriil (pnenmococcus or pono~ccns) and yeastlike organisms, a.swell as the ntlq~t o('0cc11s and colil’ornl IpJ’“, is not, borne out by this study. 1I )lfPl)(o.f II))1 (r,ntl I’calpurf 1o)t f I,ltTtlr,,r,.~.-l’lirse (~~11 111*(‘s JVCI’C. obtain(vl l’t*otjl ~)atirllts as thy %V(‘lX? :tdIllit~tYl t0 t.tW 1;lhJL 1’00111S XlCl XJ,eXtCd 011 thC Sillli(’ women on ttie day of discharge. SixI;\- patichnts wcrc: utilized, with a total 01’ 119 cultures. As seen from Table lT, 94 purt cultures of nonpathogenic IIOIIhemolyt,ic Stnph!/~ococc~r.sU@US,coagnlasc negative, wcrc obtained. There MTCYV 5 mixed cultures of the same containing different nonpathogenic contaminants.

SMITH

AN13

VARGA

Am. J. Obst. 6r Gynec. December, 195;

There were 14 other cases of nonpathogenic (avirulent) nonhemolytic Staphylococcus aureus, coagulase negat.ive, and 3 with other avirulent cont,aminants. This leaves only 6 cultures of potentially pathogenic organisms (pure or ~nisetl ) which could be the SOUIW of future infection, ;: of which were foun(l 011 antepartuni cultures and 3 on postpartum vultul+cx =_

------~ Nonhemolytic Staphylococcus albus, coxgulase positive Nonhemolytie Stapkylococccts albats, coagulasc negative, other organisms : Ephtheroids Nonhemolytie streptococci Sarcinae Nonhemolptic Stnphylococms ~UIILS, ~~oagulauo positive Nonhemolytic Stap~fzyiocorc~~s cwrcus, wagulase negative Nonhemolytic Stnpl~ylococcus nurcus, ~oagulase ncgat,ive, other organisms : Alealigenes faccalis JXphtheroids Nonhemolytic Staphylococcus aureus, coagulasc positive, other organisms: Alpha streptococcus Hemolytic Stnphylococc~rs nurc l&s, coagwlase wgat,ive, 111~s organisms:

plus

plus I 1

.I-

1

I

plus other 1

I .I

In comparing antcpartum and postpartum cultures (Table IIl), in 16 patients the bacteriology of hhe breast was alteretl. All three of the potentially pathogenic antepartum organisms wcrc found to have been replaced by knign organisms on the patient ‘s discharge: front the hospital. However. 3 postpartum pathogenic organisms were now foutul whcrc~ previously benign onus had been present. Very little can 1~ conclutletl from this, other than that hospital environment can climinat~c~ as ~~11 as ~ontributc pathogenic organisms. The remaining 10 casts of altcrc~tl blx>nst. bact.eriology wct’c nrercly a replacerncnt of benign with ;I tliff(hrtant notlpnthog~?llic: organism or an acquisition or loss of an additional organism such as ~~llcrrliqc~~~s fatwalis (1 case), Sarcina (1 case), and diphtheroids (4 casts). -

In Vitro Sensitivity Dete~))ainations.-Specimens of pus cultured from 33 cases! consisting of 11 specimens of hcmo1yt.k Stu.phylococcus auwus, coagulase posltlve, and 19 of nonhemolytic Staphylococcus ~~I’CJZLS,coagulase positive, were submitted to sensitivity tests against thrrc antibiotics, penicillin, erythromycin, and tetracycline. Hemolytic Stnphylococcus au~us, coagulasc positive, was found to be moderately resistant or resistant to penicillin in 83 per cent, t,o tetracycline in 50 per cent, and to erythromycin in 7.7 per cent (Table IV).

Volume Number

74

PUERPERAL

6

BREAST

1335

ABSCESS

Nonhemolytic Staphylococcus aweus, coagulase positive, similarly showed resistance in 94.7 per cent to penicillin, 18.7 per cent to tetrac+ine, but in 110 instance to erythromycin. The average figures for both organisms are: penicillin 88.8 per cent, tetracycline 34.4 per cent, eryt,hromycin 3.9 per cent. T~BJ,E

IV.

HEMOLYTIC ACREUS,

Tr; VITRO

SENSITIVITIES OF BREAST ABSCESS AGAINST 3 hTIBIOTICS)

STAPHYLOCOCCUS COAGT’LASE POSITIBE

PFlbicillin > 10 >

1.5

Eryt~l~ycia > 50

j

RESISTANCE

1

CULTURES

NONHEMOLYTIC STAPHYLO(‘OCCUS ACREUS, COAGULASE POSITWE

12 cases 2 cases 14 13 (mcg.).eases

83.0%

7.7%

1 case (mcg.).7 cases

>

7 cases

5o.ocJo

Ekythmmycin

1 RESISTANCE

> >

10 1.5

1S cases - 1 case 19

94.7c/o

> >

10 50

19 cases 0 cases

0

> 10 >

-11

70

16 cases

50

18.7%

3 cases iii

tests

Penicillin:

TR~TFJD

is-

Tetracycline > 10

Total

CASES

(.mits).-

14

50

(33

99 > <

10 means absolute 10 means varying and tetraeyelinc: > 50 means absolute < 50 means varying

resistance. degree of

sensitivity.

resistance. rlegree of

scnsit,ivity.

Sawyer and Walkerl” found 87 per cent resistance of Staphylococcus auwus There of breast abscessto penicillin, and 33 per cent t.o dihydrostreptomyvcirl. was no resistance to any of the following drugs, AureonlT\rcin, Terramycin, Chloromycetin, and bacitracin, in which 100 per cent scnsltlvity was noted. Walsh14 in 1949 obtained results quite the opposite of the above, wherein 51 of 57 cultures of coagulase-positive Sta,phylococcus aur.eus were sensitive to penicillin, giving a resistance rate of 10.5 per cent. Martyn,13 also in 1949, examined cultures from the nasopharynv of 130 newborn babies and found a 50 per cent ca.rrier rate of coagnlase-l)ositi\-(I st,aphylococcus, of which 55 prr Cent,W(W prnicillin resistant, but only 3.7 1~1 cent streptomycin resistant. In Viva (Clinicul) Responseto il1Ltibiotics.-Seventp caseswere treated with penic.illin alone. In 17 of these adequate response was not achieved and we, therefore, switched to DicrpsGcin (14 cases) and Achromyein (3 cases). Primarily, penicillin alone was effective in 75.7 per cent of the cases. Disparit! between this result and the in vitro sensitivity of 11.2 per cent is evident. 1)~ to various factors, clinical responsedoes not always correspond to in vitro results. A good clinical response may occur with an organism reported as resistant, ant1 vice versa. Again, organisms resistant to set, standards of levels of testing in the laboratory may respond to 1arg;c tloscs of antibiotics clinically. Dicrysticin was used primarily in 38 cn,sesand secondarily in I4 casrs, a total of 72 cases. It was found nom~ffective in only one instance of thta secondary group, therefore the total percentage value was 98.6. We can conclude that penicillin in conjunction with streptomycin as Dicrysticin (or Combiotic) is more potent in controlling Staphylococcus murem than penicillin alone. All cases responded to Achromycin (5 cases) or Terramycin (4 cases).

1338

SMITH

ANI)

VAR(iA

Am. J. Ohst. & Gyncc. Ikcmhcr. 1457

Results of Therapy Temperat,urcs as high as 105O 1”. 011 irtllnission usually dropped to ~OIWI~~ 24 hours after incision alltl clrainagc. ;rncl ~lssoriatcd antibiotic thrrapy. The patirnts who coutinurtl to run a frbdr VOI~IW~. or subseqnrnt.ly to hnvc: a spiking temperature, rrqniud redisruldicrn of locdcs rrsnlting from nn inad+ quatc original procrdnrc or the dr\-c~lolnnrnt 01’ IICW pockets. This provccl to hc the cast in 26 instances. Fortificntiorl or change of antibiotic from penicillin Was necessary on occasion to iII);ItC’ thr iflfccdnn an(l rnhiItnr<’ N’SpOtlW to the surgical treatment. The avera.ge postopera.t.ivc dudiotl III’ l~ost)it;llizi~.tio~~ was 6 to T ~IQX thr shortest, being 2 da,ys ancl the IongfJst 1 I) (lays. l~~dongrci institutional c:arr was nrcessary in casrs in whic?h l>rac*tic;rlly thr wl~olc breast was inrolvcd, Jvquiring two to thrrr quadrant incisions to ~~rotlncr proper clisulption of thr lodes ant1 rvucnation of purulrnt Itlilt~‘l’i;ll. The patients wrrr followc~l in thcs calitlicd at wrrklp irdrrvds for 3 to 10 weeks brfort: healing was c*onJl)lvtc~. Thcl c‘ncl i*casults of wide incisions wcrr fine srars and healing With minimal distortion of thr breast in a.n insignificant nnmbcr of casts. Summary within

The mrchanism of brc~ast inftvtion is rilost likrlp onr in which thr infant ac(lG~ps thr I)athogrnic: stal)hylocorvus cGthor in thr hospital or homr rnrironmrnt. ant1 trnnsn1it.s it to the brrast. U~HI~I suckling. linclt~ favorable conditions of nlilk stasis, ultrogratle invasion of thch tlnvt OWIIKS ;Ind an infli~m~natory pl’ocrss is initiatrd which may 1~ropr~~s’s to ;ihsrrss formation. Since the aorrwgr duration of xynlptoms was 7.7 (1ilyS 1)1~1’ot*rthe patirnts sought tnrdirill (2~rr. prrsona~izcd postpart,nm instructioli to nur’sing mothers SWJJJS c?WIltial. This would I)crmit earlier awar'encss c)f I)rc;lSt iXh~lOtTIJdity and nl10~ fO?* pTomt,t antibiotic therapy in or&x to vi rcurlrvrnt abscrss formation. Tnfants who rxhihit signs oi’ upper rcspirato1.y in frrtiou shonlcl bc rrmovetl t’vom thr brrast, isolatrd (manual rmptying or brrnsts institutrd t~cmpo~*ady ), and recrivr proper antibiotic care. In sr~li C’HS~S thr two conditions apparentl> nccrssary for promoting breast infrrtioll il1'C prrsrllt : (a) inability 01’ sick infants to frtbcl well with resultant illrf~~vtnal rrnldying of brrasts. thrl*rl)y pronlc$ing dasis and sta.gnation, ;Itltl (I)> t.hl, prrsr*n(*e of iI p:dhog.cnic organism in thr ixppcr’ rrspir*a.tory twvt ot’ tllcb illfilnt. Tnfants of mothrrs who (lispl;ly I)IY~;ISI infrvtion should br l)lacrtl ill thr 111 srnallrr hosl)itills. \srhrn isolation nnrscry ant1 gircfiil antibiotic* tr~c~iltm~tlt. in;lstitis apprnrs on thr maternity- floor. it tvc~ul(l l,(b frasil)lr to iItllnillist(A,* antibiot,i(*s prophylartica.lly to ;I11 infants ill illi iltt(‘tlll)t to [)l’cb\;rrlt CI’OSS infcrt.ion. All At ( ‘Cook (‘cnlnty TJoslGtal this l)r;ivt ic.c, ~~c~ultl 11(x vir*tnally impnssibl(~. within 18 to 72 hours of clrnormal ]JOSt~)iJ?'tlIIJl patients I('i1V1' thcfi iiistitittion Also. thr lirrty, long brfol*r signs ant1 syrrtptoms oi’ ilif~~~tiotr iin’ iilanifrsttd. tlistribution 01’ tlrngs to infants rlumbrt?lig in rscrss of I.800 prr mont,h is in itThe ultinmtc~ bnt drastic rnrasurr for prrvrJitinn srlf il 1,rdiihitivr procetlurc.

Volume

74

h’umher

6

PUERPERAT,

BREASl’

ABSCESS

1339

of breast infection would bc to eliminate all breast feeding during periods of increased breast infection. Breast feeding could be resumed when the infection has been curtailed. This protracted series of augmented numbers of breast infections would indicate that more than an “outbreak” has occurred. It is more plausible that a new norm or standard of bact,erial virulence has been established, which is refractory to the more commonly nscd antibiotics, part,icularly penicillin. Conclusions 1. The incidence of breast abscessat Cook Count,y Hospital has markedly increa,sed in frequency during the past, two years. 2. The main organism isolated in this series was pathogenic ~S"tnph~yll;l~~~~~:~~~ wuwt~s. Occasional nonpathogenic contaminants also were present. 3. Although penicillin in large dosage apparently showed good clinical response in 75.7 per cent of tlic cases,sensitivity tests (SS.8 per cent resistance to penicillin) would indicate that penicillin thtral)y is of little or no value. Other drugs, Dicrysticin, streptomycin, dchromg-tin, or Terramycin, would offer more hope in combating and controlling breast abscess. 4. Varidasc incorporat,ed into jelly and applied directly to the wound promotes rapid elimination of necrotic slough and discharge, promoting a clean, readily granulating wound. 5. Routine cult,ures on admission and discharge of patients indicat,e that hospital contamination is no more a source of infection than nonhospital environment, Three patients who were admittrd with potentially pathogenic organisms showed benign organisms on discharge, while 3 patients who entered with benign organisms acquired potentially pathogenic organisms. 6. Early incision and drainage arc imperai-ivc. Inflamed, indurated arcas should be incised before fluctuation or other signs of purulcnt content of the abscessare discernible. 7. The type of incision clcp~nds on the cstcnt of the lesion. If less than a quartrr segment of the breast is involved, circumareolar inrision will sufficr; otherwise an extensive radial incision or mnlt,iple incGsions, if necclssary, should be employed. 8. Preventive measures are discussed. References 1. 2. 3. 4. 5. r;: 8. 9 10: 11. 12. 13. 14. 15.

Sherman, Alfred J.: Obst. & Oynec. 7: 268, 1956. Colheck, J. C.: Canad. &I. A. J. 61: 557, 194% Knott, F. A., and Blaikley, J. B.: J. Obst. & Gynaec. Hobbs, B. C.: Bull. Hyg. 19: 391, 1944. (Abstract.) Pyle. L. 12.: AM. J. OBST.& G~wz.55: 676,194S. MeGuinness, F. G., and Musgrove, G. S.: Canad. M. A. Gibber& G. F.: AM.J. OBST. & GYICEC.~~: 1038,1953. Brit. M. J. Martin, T. B. M., and Whitehead, J. E. M.: Williams, R. E. 0.: J. Path. & Bact. 58: 539, 1946. Matthews, E., Atkinson, H. F., Raunsbury, P. T., and 54, 1949. Duncan, J. T., and Walker, J. J.: .T. Hyg. 42: 474, 1949. Torrep, J. C.,, and Reese. M. K.: Am. .T. Dis. Child. 69: Martyn, G.: Brit. M. J. 1: 710, 1949. Walsh, Snthony: Lancet 2: 635. 1949. Newton, M., and Newton, N. R.: Purg., (Tyuer. & Obst.

Brit.

Emp.

51: 386,

1944.

J. 61: 356, 1949. 1: 173, 1949. Clegg,

H.

3OS, 1945. 91: 651, 1950.

W.:

Rrit.

M.

J.

1:

--;

Chxago Materuity Cent<,1 Cook County Hospital Philadelphia General .Hospital

~~- .__. n .4“1 0.14 0.39 ~. __...

020 0.18 0.79

0.19 0.34 1.19

0.35 1.13 1.28____----...

0.14 ----w 1.35 0.88

0.63 0.89 __-

Volume 74 Yumhet

(r

I’UERI’ERAT,

RR,EAST

AT3RCESS

1:‘,+1

TII~J conductors of this rtudy bewho drveloped breast abscesses nurs~l their infants. lievc,l that they could show a rlt~c~ase in I~rcast :I~WWSW ill nlothers tliscllxrgr~l 1111 the liay of dclivcr~ or t.he first l”‘“t1larCInll da? ! \Vith the findings uf pe~licillinThese variances seem to be statistirally significant. resistant caausative organisnls in 8X.S per cent of this series, should we not seek further In the series presented here tonight, nipple hospital correlation rather than den\it? cult,ures from 60 patients produced but ti positive staphylococcus cultures. But 3 of these Cultures of the abscesses, however, produced a preponderance of were coagulase positive. these organisms. It appears that the patient’s immediate environment way not conSo, once again, perhaps the hospital, pllrhaps 11y wn~ of taminated by these organisnx its personnel, has given to the baby these organisms (even during the usual :i tlay sta!, at the Cook (‘ounty Hospital) and the Irabies have introduced the organisms into thrS patients’ breasts through suckling. The presence of a plentiful and a rather permanent source of infection (contaminated environment and carrier personnel) and production antI exposure of an inexhauatihle supply of susceptible newborn infants permit eas.v propagation. The treatment affordetl these patients admitted to the Cook County Service seems to 1~ most alleqnate. Is it really so surprising that the clinical response and the in vitro Regardless of the use of antihioticas (and in sensitivities do not necessarily correspond? days prior to their usage) di(l not allscesses cure themselves after spontaneous rupture 01 wille incision and drainage! conclusion that hospital contamination is no more a It appears that the authors’ source of infection than the nonhospital environment, in view of previous studies, is lo 1~ c~uestioned. The baby ax a possible and probable source of transmission has been ignorrll. The relatively stable and lox incidence at the Chicago Maternit? Center ma\- flIrther suggest the possil~ilit~ of a hospital-offerell organism. DR. VARGA (Closing).-It is remarkable t,hat the percentage of hwast almesses recorde~l in patients d(~l~ver~d 1)~ the Chicago Maternity Cent,rr over the 3 year periotl outline11 hy Ur. I)ye should l,e only half as great as that encountered at Cook i’ountv Hospital. This is in keeping with the view that hospital environment is the main source of infection in this condition. Morrover, it suggests that a return to home deliveries might he desirable in order to avoid breast infection; or, on the other hand, a prcferenre for prolonged postpartum hospitalization, so that incipient infection can be recognized ant1 treated. However, we included in our series abscesses which developed in patients delivered at home without medical assistance, and others who were delireretl h\- the personnel from the (:hicago Maternity (lenter. T assume that all of these latter cases have heen include<1 in their series. l)elet,ion of these from our large number of cases wonl~i alter our statistics very little, whereas the adclition of these cases would materially increase Maternit\(!enter’s average figure to a degree proportionate to ours. The neecl for our apparently racliral surgical approach has been questioned and a more conservative methot of incision and drainage suggested. We outlined the technique of circumareolar incision as applicalde to smaller. well-localized lesions. Failure in some of our earlier cases coul~l tle related to inadequac,v in the extent, of incision, interfering with accessibility to some of the involved Ioeiiles, thus necessitating subsequent reopening of the wound. 1 wish to re-emphasize that the Ilrajority of our patients delayed in seeking medical care and when f&t seen hat1 involvement in more than half of the l)reast. The numerous affecte(1 lorules cannot l~r reachell via a miniature incision. ,4s long as pus is retained in one locule the sign s anal syruptonls will not abate, and the tliseasck may pr<,gress to involve adjacent areas of unaffected ljreast tissue. Our bacteriologic studies would have been more complete had we inclu(letl cxultures obtained front the nasopharynx of a cornparal,le number of hospital personnel and newhorn infants. Perhaps this might l,e attempted in the near future. It has l)een established 11~ many authors, however, that hospital personnel 110 have a higher incidence of pathogenic. organisms in their environment. It is evident also that newborn infants soon harboz similar organisms. The important factor relevant to breast infection is the transmission of these organisms to the healthy lactating breast.