Care for preterm infants. (via Google Translate)
[Des soins à donner aux enfants nés avant terme.]

Click to view the original French text.
Par M. S. Tarnier.

Bull. Acad. Med. (Paris) 14:944-954, 1885.

  Gentlemen, Everyone knows that children born prematurely die in large numbers, and that, to have any chance of sustaining them, they must be surrounded by special care, at the top of which must be placed a relatively high temperature and a good food regulation. To these treatments, which have been very well described in an excellent memoir published on this subject by our colleague M. Guéniot, I have added two new means: the use of an incubator and force-feeding, which were one and the other put to good use for the two children whom I present to the Academy today.

The incubator, which has been in use for several years, has proved its worth, and it is well enough known for me not to describe it. The children I place there are kept there at a temperature which I have varied, depending on the subject, from 30 to 37 degrees centigrade, and which is all the higher as the child is weaker. I am not yet able to specify what is the best temperature; however I must say that I usually bring the temperature to 32 degrees. The children placed in the incubator remain there for a variable time, from a few days only up to six weeks. We take them out momentarily each time we want to clean them up or breastfeed them. These out-of-the-incubator cares had me, at first,

To the use of the incubator, I added force-feeding. After a few attempts which I had at first made from time to time, force-feeding has been regularly put into use at the Paris Maternity Hospital since October of last year, and I have already benefited from it a fairly large number of children born before term.

To practice this force-feeding, I make use of an apparatus which is a diminutive of that which Doctor Faucher employs for adults. The force-feeding device for children consists quite simply of a red rubber urethral catheter (No. 16 of the Charrière line). At the end of this probe, a glass cup is fitted, which is found in all manufacturers of surgical instruments and in all herbalists, where it is sold as an artificial nipple.under the name of my good friend Doctor Bailly. -- With this small device, which everyone can improvise, nothing is easier than force-feeding a child: The latter being placed on the knees of the person who will carry out the force-feeding, the head slightly raised, the probe is wet, then introduced to the base of the tongue, and the child by instinctive swallowing movements makes it penetrate to the entrance of the esophagus; the probe is then gently pushed to make it travel the entire length of the esophagus, where it travels very easily. After a journey of about 15 centimeters, including the mouth and the esophagus, the end of this probe arrives in the stomach; the alimentary liquid is then poured into the cupule and soon this one, by its gravity, penetrates into the stomach and the cup is emptied as well as the probe which follows it. After a few moments the probe is withdrawn, but it must be done with a rapid movement because, if one proceeded slowly, the food liquid would follow the probe and be expelled by regurgitation.

What food should be chosen for force-feeding children? I tried donkey's milk pure or cut either with sugar water or with butcher's meat broth; I have thus obtained some success, but I believe, it will not surprise you, that woman's milk is still preferable, and the nurse by pressing her breast can make her milk flow directly into the glass cup.

How many times should the child be force-fed in twenty-four hours? How much milk should enter the stomach with each gavage? Unfortunately it is impossible for me to answer these questions in a precise way, because the number of meals and the quantity of milk ingested must vary with the age and strength of the child, both at the beginning and during the lesson. breastfeeding by force-feeding. I will say in a moment how these questions have been clinically resolved for the two children before you. But if I had to establish a general rule, I would formulate it as follows: The meals will be all the more numerous and the quantity of milk ingested at each force-feeding will be all the less as the child is younger and weaker.[1]

With too copious force-feeding, a very curious phenomenon occurs: the child rapidly increases in volume and weight, but this increase is due to considerable edema of the whole body of the child. As this edema disappears quickly with a more moderate diet, I think we can explain it by hypernutrition . But if, instead of diminishing the quantity of alimentary liquid, we maintained it, and especially if we increased it, we would soon observe indigestion, and the children would succumb with gastritis and enteritis. Therein lies the greatest danger. To succeed, the milk must be ingested in small quantities at each meal, except to multiply the meals.

The child I have the honor to present to you is a twin born on June 8th. She remained in the incubator from June 8 to July 20, that is to say for six weeks.

Here is how her diet was conducted: From June 8 to 12, she was force-fed hourly with 8 grams of woman's milk per force-feeding. -- From June 12 to July 5, she was force- fed every three hours with 16 grams of woman's milk per force-feeding. In the interval between two force-feedings, the nurse poured milk into her mouth; but we know how difficult it is to assess the quantity of milk ingested under these conditions, because children swallow badly and spit out part of the milk that is poured into their mouths. It is about the same when you want to ingest the milk by means of a teaspoon. -- From July 5, the child suckled and was no longer force-fed.

The initial weight of this child was 1020 grams, but it decreased until June 29, when it was only 850 grams; from then on, it gradually went up, and the child now weighs 955 grams. These different weights are indicated day by day on the graphic plot that I put before your eyes.

You will ask me how pregnant this twin's mother was when she gave birth. On this subject, I do not know anything precise and I cannot affirm anything, because questions of this kind are always very difficult to resolve, and, whatever the solution adopted, one can always oppose some doubt. All I can say is that the woman repeatedly said she was only six months pregnant. But this is a simple assertion. Still, the child weighed only 1020 grams, his skin was red, semi-transparent, his tissues had a gelatinous consistency. All her characters agree and make me think that this child was about six months old when she was born. But, I repeat, on this point I cannot affirm anything precise.

This woman's other twin was placed in the incubator, where she remained until her death. She was fed exactly like her sister, whose story I have just traced. At her birth, June 8, she weighed 1105 grams, that is to say 85 grams more than her sister; then her weight fell to 1015 grammes, and this young lady died on July 3, after having lived twenty-five days. At his autopsy, no appreciable lesions were found. It is impossible for me to say why this twin succumbed, while the other, the smaller, survived. The second child that I present to you was born in Paris, in the city, with his parents, who kept him for three days by giving him a little sugar water to drink. At the end of this time, the doctor of the family having declared that this child would not rise if one did not place it in an incubator, it was brought to the Maternity, where it entered on May 23 of this year. He was placed in the incubator, where he remained until July 5, that is to say for forty-two days.

From May 23 to June 12, he had a meal every hour: at every odd hour, he was force- fed with 8 grams of woman's milk; at every even hour a nurse poured milk into his mouth. From June 12, he began to suckle, but for two more days they continued to force-feed him four times in twenty-four hours. I must say why the force-feeding was continued, when the child could suckle: it is because the sucking of the nipple tires some children, and the feedings would soon be insufficient; that these children would eventually become numb and die of hunger if one did not take the precaution of maintaining and reviving their strength by force-feeding practiced from time to time. - - From June 14, the child in question here was able to nurse satisfactorily, When he entered the Maternity, three days after his birth, this child weighed 1100 grams. His weight went down to 1000 grams, then it went up gradually; today it is 1500 grams.

The parents of this child affirm that at the time of his birth he could not avoid more than six months and one week of intrauterine life. The child's weight and appearance lead me to believe that this assessment is probably correct.

I am convinced that the two children you see owe their lives to the incubator and the force-feeding, and I think that with these two means we will succeed in saving a good number of children who, without them, would have succumbed. But after how long of intra-uterine life can a child born before term have any chance of being brought up? French law admits that a fetus is viable from the end of the sixth month of intrauterine life (180 days). Midwives, on the contrary, until recently professed, I could even say yesterday, that if six-month-old fetuses are legally viable, it is almost impossible, in practice, to bring up children who are born in the course of the seventh month. Today, thanks to the incubator and force-feeding, the term of viability accepted by midwives will be lower than in the past, because I have been able to support a few children who very likely had only six months and a few days of intrauterine life. Will we be able, using these means, to raise children with only six months of intrauterine life (180 days), as admitted by French law? I am very willing to believe it. Will we even be able, in a few exceptional cases, to succeed in bringing up children born before the hundred and eightieth day? I don't want to despair of getting there.

M. Blot: I am happy to note that Mr. Tarnier seems to agree with the opinion which he had formerly fought against a large number of us, namely that precision, when it comes to fixing for children a mode of administration of the milk or the mixture of milk necessary for their food, is not more possible than when it is a question of establishing the exact age of the uterine life of a newborn.

I will recall, from this last point of view, that the weight of the child cannot provide a sufficient means of fixing this age. This is how I reported the case of a child unquestionably born at term, who weighed only 1300 grams; and this low weight resulted from the fact that the uterus, otherwise well developed, was strewn with haemorrhagic foci which diminished its volume accordingly.

As for the incubator, which incontestably gives good results, I would reproach it for being applicable only to the hospital, and for never being able to pass into practice.

M. Tarnier: I beg your pardon, it went through it, and not through my hands.

M. Blot: Besides, there is something much simpler than the incubator, which one meets everywhere and which fulfills the same purpose, it is the cotton wool with which one surrounds the child.

Same for force-feeding, you might be able to do it in the hospital, but I highly doubt it's applicable in the city.

M. Féréol:: Five and a half years ago, I gave my care to a child who was incontestably no more than six and a half months old; he had that gelatinous, red aspect, the slender limbs that M. Tarnier showed us just now. He was surrounded by cotton wool and warm water and, above all, he was marvelously cared for by his two grandmothers who, taking turns, gave him a teaspoonful of breast milk every hour.

M. Tarnier: I never intended to claim that we did not obtain brilliant results before the incubator and force-feeding; I only wanted to say that successes were then extremely rare, whereas today, by adding to the care of the past the means that I have just indicated, we will succeed better and much more often.

M. Blot made a point of recalling that I once declared that it was necessary to determine with precision the mode of feeding of newborn children; but he believes me to have come back today to another opinion and I would think that the rules of this diet must remain undecided; but he is wrong. The truth is that, a long time ago, I appealed to the Child Health Commission, to the Academy, to the entire medical profession, to make every effort to find the precise rules to which the diet artificial children had to be submitted. I'm wallowing in ignorance about this...

M. Blot: We are all stuck in it, and always will be.

M. Tarnier: I am still looking for the best method of blending milk and, since the Academy did not want to undertake this research, I hope one day to be able to clear the ground on this difficult question.

As for the use of cotton, with all due respect to M. Blot, I do not believe that it can ever replace the incubator. Put a mountain of it, if you will, around the child; the latter will none the less breathe the outside air; while in the incubator, the air entering his lungs will have a warm and beneficial temperature.

Here is a proof of the effectiveness of the incubator: All the obstetricians have seen a good number of children affected by sclerema die quickly, in spite of all the care lavished; Mr. Depaul [2] said that out of twenty children taken from the sclerema, sixteen died. Now it suffices to place these children in the incubator so that in twenty- four hours the resurrection is complete; I have witnessed this fact many times in the Maternity. Get, if you can, such results with cotton.

M. Blot: Certainly, with cotton and massage.

M. le Président: Mr. Tarnier saw with what attention the Academy listened to his communication; it is that in fact, independently of its scientific interest, it has the merit of opportunity; at a time when population growth in France is undergoing a worrying slowdown, it is not indifferent to learn from the mouth of Mr. Tarnier that, thanks to the use of his incubator and the method of feeding which he calls force- feeding, one can save seven or eight times more children born before term than one did before; when one is poor, there are no small savings.


[1] With the apparatus I described above, when the probe is pinched between two fingers, in order to prevent the flow of milk, and this liquid is dropped into the cup, the latter contains approximately 8 grams of milk when filled to the point where it suddenly flares out.

[2] Depaul, Encyclopedic Dictionary, art. Newborn, p. 675 to 690.