I hesitate to write even more on a subject that has been so thoroughly
discussed over the past few days.  A lot of interesting points have been
presented and I don't really have anything of substance to add.  I found the
physical therapist's perspective very intersting and sensible.  However,
despite the volume of discussion,  I feel a continuing need to restate certain
things that seem to me to be getting lost in the shuffle.

1.  One thing that has come out of this discussion is that the breast is not
like other body parts, e.g., a swollen ankle.  I have also used the swollen
ankle analogy in trying to explain to co-workers why, in general, cold is more
appropriate than heat.  However,  it is clear that, because of the physiology
of the breast, one is dealing with two processes - tissue edema and milk flow
- that are logically treated in opposite ways.  Sometimes, especially when
engorgement has not progressed too far,  a little heat will get the milk
flowing; other times,  nothing will move until the edema is decreased by cold.

2.  Although some have argued  eloquently for the theoretical basis for cold
and against heat, others have described their CLINICAL experience of
situations where heat has been effective.  I have also seen that in some
situations the JUDICIOUS  use of heat can be one part of effective treatment.
When clinical experience contradicts theory, does one ignore the evidence?  I
think this argues, as many have said, for more research on the subject.

3.  As with almost all disputes, the truth is usually closer to "both-and"
than "either-or".  Understanding the rationale for our interventions should
lead to using them appropriately.  And it still seems  to me that, although
cold is the more appropriate treatment for pathologic engorgement, there can
be a place for heat in certain cases.
Why be so rigid when experience has shown that there are various approaches
that can be useful in different situations?   Miriam Levitt RN, IBCLC