The period between the Franco-Prussian War (1871) and the beginning of World War I (1914), rich in scientific discoveries and filled with artistic creation, opened a new era in medicine. A high infant mortality rate, which was fueled by lack of basic hygiene, curtailed population growth in various European countries. Governments were worried, especially in France, (1)(2)(3) where industrialization and colonization were in progress. The “European Empires” needed men for industry, the military, and the colonies. Influential political men such as Dr Bourneville, a senator of the French Republic, (4) turned to obstetricians to solve the acute problem of infant mortality and address the depopulation issue. This powerful physician facilitated the creation of modern maternity units managed by certified obstetricians instead of surgeons.Maternal mortality had decreased markedly, starting in 1890, thanks to the introduction of antisepsis. A participant in this effort was the young doctor Pierre Budin, a senior resident of Stephane Tarnier, the leader of French obstetrics. (5) In 1874, he was sent to study with Joseph Lister in Edinburgh (6) to learn the preventive treatment of surgical infections. Puerperal fever had decimated maternity units to such an extent that some were closed intermittently. This serious issue absorbed so much of Dr Tarnier's energy that he was forced to take a leave of absence to prevent his health from deteriorating. A friend of Budin, Lucas Championnière, (7) a young surgeon, had preceded him on this path by working for a few months with Lister at the Royal Infirmary in Edinburgh. In Paris, he already was applying the antiseptic method of Lister with extremely good results. (7) Shortly after Championnière, Budin made the trip to Scotland and learned all the details of the antiseptic method. He also benefited from the teaching of Duncan, the chief of obstetrics. Lister recommended to Budin that he visit Professor Karl Thiersh in Leipzig, Germany, (6) to see for himself the use and beneficial results of the antiseptic method, which consisted of hand washing and wound spraying with carbolic acid. Incidentally, Professor Thiersh switched later to salicylic acid. Budin returned to France with new knowledge in obstetrics and surgery. This astonishing fellowship would not have happened without the extraordinary development of the railroad, which facilitated the movements of many industrious men. A new international scientific and cultural dimension opened and allowed the formation and transmission of new ideas.The antisepsis concept had been demonstrated, but ignored by the medical community, by Ignaz Semmelweiss in 1847. (8) (Editors Note: See the Perinatal Profile by Istvan Seri in the June 2007 issue of NeoReviews.) Lister, convinced that the “germ theory” of Louis Pasteur was correct, had revived the concept. When Budin returned to Paris from his fellowship, he was convinced that antisepsis could be the first line of defense against puerperal fever. He did not anticipate that the introduction of antiseptic solutions in obstetrics would be an uphill battle due to the adamant opposition by some practitioners and surgeons.In 1879, Louis Pasteur identified the cause of the dreadful disease in the blood of postpartum infected women. The culprit was a bacterium, a coccus assembled in chains that was named Streptococcus by Rosenbach in 1884. Hand and vaginal washing with a modified mercury bichlorate antiseptic solution, (9) progressively decreased the rate of the deadly disease. This solution replaced carbolic acid, which was too irritating for hands and mucosae. Other antiseptic solutions were introduced later. High doses of mercury in solutions, as adopted by the French Academy of Medicine, also had significant, and sometimes lethal, toxicity effects when introduced into the vaginal or uterine cavity for disinfection purposes. Many midwives in France used it indiscriminately without serious supervision. (10)The continuing fear of surgeons was that the obstetricians would take over the field of gynecology, which the surgeons jealously guarded. The fight even reached the surveillance council of the Assistance Publique, where the surgeon's lobby was too well established to be altered. Obstetrics remained under the auspices of surgery, but a serious incident pushed the balance in favor of the obstetricians. On Easter Monday 1881, the Director of St Antoine Hospital searched in vain for one of the 13 on-call surgeons for the city of Paris to handle a difficult delivery. Desperate, the Director sent Budin a messenger. Luckily, he was not attending religious services that day; he had stayed home to finish an article. Like Bourneville, he endorsed republican ideals that were in conflict with those of the Catholic Church. He hailed a cab and asked the driver to rush him to St Antoine Hospital, located 30 minutes away. He had taken a set of forceps in his bag. When he arrived, he found a young mother in agony, with her eyes rolled up. Rapidly using the forceps, he extracted a dead infant. The mother died soon after. When he left the hospital, he was so upset that he had to stop behind a column to wipe away the tears.At the request of the Director of the hospital, Budin wrote a report that detailed the circumstances, timing, and story of this tragedy. Dubrisay, the Director of the Assistance Publique, made this event the starting point of a full restructuring of the maternity units of Paris hospitals and proposed an amendment for a “concours” (competitive examination) for the position of Obstetrician of the Paris Hospitals. The amendment was adopted in June 1881 by the Municipal Committee of the City of Paris. (10) Budin and his friend, Adolphe Pinard, became two of the first laureates. (6) The discipline of obstetrics finally was recognized. Budin was appointed Obstetrician-in-Chief of the Charity Hospital in Paris shortly thereafter.Budin would remember the face of the young mother for the rest of his life, which influenced his care of women. He was not married at that time, had no children, and decided to learn from his patients. Their lives became very important to him, and he devoted more time listening to their stories. He slowly emerged from his medical books like a butterfly from a cocoon. He became more polite, more helpful, and more understanding. He found the stories of the young mothers poignant.As French surgeons lost their grip on obstetrics, their hostility toward Budin grew. In 1885, in need of surgery for himself, Budin called on a British surgeon, Lawson Tait, to perform the laparotomy (6) to remove an echinococcal cyst from his abdominal cavity. This action, considered an insult by the influential Paris surgeons, delayed Budin's appointment to the rank of full professor. By 1892, maternity units no longer needed to be closed because of puerperal fever of epidemic proportions. The fight against maternal mortality that had haunted his mentor, Tarnier, had been won. (6)The fight against infant mortality was on the minds of the obstetricians, who also cared for infants until age 2 years. The solution to the problem came to Budin during maternal prenatal visits. Astute and acute observation skills, along with excellent data collection, led him to an original approach to infant mortality. He explained it in his book, The Nursling (11): “I took care of the newborns and was stricken by the response made by the women I had previously delivered when they came back for another pregnancy. I asked them what had happened to the previous infant they had given birth; I was told often: ‘He died!’ In fact, after discharge from the hospital, their only guide (to child care) was the vague experience of grandmothers, of the concierges, of herbalists (pharmacists). Filled with various biases, they had accumulated mistakes; their children became sick and died.”The causes of infant mortality at the end of the 19th century were well known and included primarily gastroenteritis, especially during the summer months. Another adverse factor was the growth of artificial feeding, replacing human milk with milk of poor quality frequently diluted by merchants and already infected by the long transport from the farms. Budin studied the basic rules of hygiene and nutrition of the newborn. “The high infant mortality was due to the lack of follow-up, good advice and special care.”In 1892, motivated by his initial observations and with the help of the Director of the Charity Hospital, he created one of the first well baby clinics in France. A previous attempt by Dr Herrgott from Nancy, who provided a stipend to mothers who breastfed, (12) may have attracted his attention. After attaining local success and because a crowd of mothers attended the clinics, he convinced the administration of the Paris hospitals to expand to other hospitals the concept of maternal education, promotion of infant nutrition with breastfeeding, use of sterilized milk in sterile bottles (Budin had also been a student of Louis Pasteur), and growth monitoring with scales for infants. He benefited from the enormous advantage of the Paris hospitals being under a single administration of the Ministry of the Interior. (13)(14)(15) Budin was supported in his work on the importance of human milk feeding by many colleagues, including Dr Gaston Variot, Chief of the Sick Children's Hospital in Paris, (16) who expressed his feelings during a meeting of the League Against Infant Mortality, in 1902 at the Sorbonne: “If the mothers knew the high fragility of the life of the newborn in the first few months of life, the difficulties and traps of bottle feeding, and the risk they impose on their baby, they would breastfeed immediately.”Budin, with the help of a dedicated pharmacist, Charles Michel, (17) continued to study the chemistry of milk and how to deliver it better. He invented a system for pumping human milk manually and described how to detect clinically infected human milk. He modified rubber feeding catheters (1886) for the nutrition of the smallest infants, using the technique of gavage employed on farms to produce liver hypertrophy in geese. The small apparatus included a graduated small glass container similar to the plasticized models currently used in nurseries. All the details of this succession on the improvement of infant feeding are well described in his manual of infant feeding published in 1906. (18)By 1895, Budin was in charge of the Port Royal Maternity and became full professor in 1897. (19) On his first visit, he was horrified by the unhygienic conditions to which the mothers and babies were subjected. The small pavilion that sheltered the incubators of Tarnier was poorly organized. He forced the Midwife-in-Chief, Mrs. Emilie Henry, to resign. This energetic woman had been directed by Tarnier to raise the money to build the pavilion in 1890. (20) Budin appointed one of his assistant physicians, Dr Perret, to take over the care of the “weaklings.” He then “medicalized” obstetric and neonatal care, placing the midwives under his control. Before his arrival, the Midwife-in-Chief was the equal of the Surgeon/Obstetrician. He took over the teaching of obstetrics and renovated the maternity unit and the pavilion for the “weaklings.” Upon Tarnier's death in 1898, (5) Budin took charge of the newly built Tarnier maternity unit. He continued the work of improving the use of infant incubators (21)(22) for preterm infants and weaklings and apparently inspired Martin Couney, (21)(22) a young German physician. Dr Couney, who had a taste for enterprise, helped Alexandre Lion, the engineer of the first servocontrolled incubator, to present and care for the preterm babies of the Charity Hospital maternity at the Berlin Industrial Show in 1896. Later, successful exhibits in fairs and amusement parks across the world, including the United States, led Couney to settle in 1903 at Luna Park. Despite controversy, (21)(22) the incubator show attracted the attention of Julius Hess (Editor's Note: See the Perinatal Profile by Tonse Raju in the October 2006 issue of NeoReviews), a young pediatrician in Chicago, who corresponded with Couney. The design of the first American preterm newborn care unit received some discrete input from Couney. Although Couney was earning a good living with the incubator show and providing good specialized service to New York pediatricians, Budin wrote the first comprehensive book on the newborn in 1900. (11) This masterpiece was translated into English in 1907 as The Nursling. Both junior and senior neonatologists would find this book a rewarding read.In 1902, with Paul Strauss and the help of the philanthropist Theophile Roussel, Budin founded the League Against Infant Mortality, (23) which concentrated all efforts to prevent threats to the health of infants. Various organizations working toward the same goals very quickly achieved extremely good results. In numerous French counties, infant mortality rates, which were as high as 288 per 1,000, fell to 112 per 1,000. (1)(2)(3) This was made possible by establishing infant clinics; training physicians, nurses, and midwives; and tracking results. This success story soon spread beyond France's borders.Budin also contributed enormously to the field of obstetrics and assisted Tarnier in the production of the Manual of Obstetrics. (24) Budin's doctoral thesis, “Of the Fetal Head,” (25) remains a classic of obstetrics. He had designed an ingenious artificial bronze pelvis to study the descent of cadaver fetal heads of different sizes. He was a member of the French Academy of Medicine as well as multiple European academies. He also was a member of the Bostonian Gynecological Society (6) and numerous philanthropic societies. (6)Certainly, Dr Budin was not the man at the origin of antisepsis; Semmelweiss and Lister preceded him. He did not invent the modern incubators for infants; Tarnier did. Herrgott from Nancy preceded him in the infant's postnatal visits. However, he possessed the genius of grasping ideas and had the ability to pursue concrete projects with an intense tenacity until achieving success on a large scale. He was a link in the chain of great academicians who transformed medicine at the turn of the 20th century. A compassionate, very observant, and creative obstetrician and educator of mothers, Budin had the ability to convince, at the right time, administrative, medical, and political spheres to pursue a simple pilot project, the infant clinics, that led to a marked decrease in infant mortality at the beginning of the 20th century.All his life, he worked with a group of young and extremely dedicated assistants such as Crouzat, Maygrier, Perret, and Bar. Despite his work load, he managed to travel throughout Europe, attending the first international medical meetings of the time. He was an avid reader, and his favorite authors included the philosopher and historian Hippolyte Taine and Russian novelist Ivan Tourgueneiv. (6) He attended the theater weekly. One of his patients was the famous actress Sarah Bernhardt. (6) Jean Richepin, the poet and playwright, was a very close friend.While doing outreach teaching in Marseille in January 1907 (26) on the topic of infant mortality, Budin contracted a deadly pneumonia and died in a hotel room. Before his death, he dictated his last will to his colleagues who were attending at his bedside: Professor Paul Bar succeeded Budin as head of the Tarnier maternity unit in Paris (27) and leader of French obstetrics.Pierre Budin did not see the final results of his work. Mothers were now better educated in infant healthcare, and increasing numbers of infants and children survived and reached adulthood. However, he would have been terribly saddened to see the loss of their precious lives to the cannons of World War I only a few years later. Although he was an advocate of the availability of sterilized, controlled milk, he would have been greatly depressed by the progressive decline of breastfeeding in industrial countries over the next 75 years. In contrast, he would have been heartened by the remarkable decline in infant mortality that has been achieved in the 100 years since his death. Pierre Budin must be credited with the creation of the modern concepts of preventive pediatrics and obstetrics, promotion of primary care clinics for infants and young children, and recognition of the importance of promoting breastfeeding. All of these concepts are expressed and elaborated upon in his major book, The Nursling. (11)Marie Therese Budin, his wife of 14 years, continued the education of mothers started by her husband. The Foundation Pierre Budin (28) was created and later became the “Ecole de Puericulture.” A model infant clinic was opened to the public on May 24, 1909, by Emile Loubet (ex-French President).On March 5, 1923, Marie Therese Budin (29) received the high distinction of the Legion d’Honneur. In her response, she said, “Everything I did, I did for love of my husband; then for love of infants and their mothers, who are frequently admirable.”