Andrés Martínez Vargas, the Founder of Modern Paediatrics in Spain

can confirm the presence of tuberculosis” . certain cases the examination of temperature can be of great service. After numerous observations I could convince myself that in latent tuberculosis there is a temperature under 37° for long periods; and this prolonged hypothermia, combined with other symp‐ toms, will serve to reveal the existence of hidden tuberculosis....This hypothermia is persistent. I have discovered twelve cases in children and young people with these characteristics, which were (De tuberculose,


Introduction
Unlike the history of Spain, which has been the subject of many studies and publications by authors of recognised prestige, the history of Spanish medicine in general, and of Spanish paediatrics in particular, are not well known to the wider world. The contributions to our scientific heritage made by several Spanish doctors are plentiful, pioneering and important. Andrés Martínez Vargas (1861Vargas ( -1948 is considered the founder of modern Spanish paediatrics. His extensive work is not valued highly enough and he still remains in the shadows. This text is intended to be a fitting tribute to his fascinating life and works.
As a result, the author has carefully read many of his texts, drawing conclusions that aim to show the real nature of this master of paediatrics, one who loved his country.

The first stages in his life
Writing about Professor Andrés Martínez Vargas means writing about the founder of modern paediatrics in Spain. His personal life and career present so many facets that it is difficult to summarise them.
He was born in 1861 in the city of Barbastro, in the province of Huesca. Barbastro is for many the main point of entry from the Aragon region to the Central Pyrenees. The oldest of seven children, and the son of a barber in the city, whose establishment was located in the central Plaza del Mercado market square, he clearly stood out in his primary school studies at the Colegio de los Padres Escolapios School in Barbastro. He was first cousin to the acclaimed regenerationist and thinker Joaquín Costa Martínez . Joaquín Costa was a great Spanish visionary, a fighter, an idealist, who coined phrases like "escuela, despensa y siete llaves para el sepulcro del Cid" (school, larder and double-lock the tomb of El Cid). With his ideas he was instrumental in the first Spanish irrigation systems, public works, the Europeanisation of Spain and he always felt close to the people he served until his death. Despite the age difference, this man, with whom Andrés Martínez Vargas had a close relationship, must have been a role model for him [1,2]. With no medical background in the family, in 1877 he began studying medicine at the University of Zaragoza, finishing his studies at the age of nineteen with an Outstanding grade and Extraordinary Degree Award. He moved to Madrid and, under the supervision of Doctor José Salamero Martínez, defended his doctoral thesis (1881) "Clorosis: crítica de sus teorías Medicine. He rejected the good financial deals they offered him and returned to Spain. He described it in the following way: "I travelled to North America in 1886, then from New York to Veracruz, and in that city and in Mexico I was offered two well-paid medical positions, which I did not accept as I only wanted to serve Spain......." [5]. Once back in his country, he learned that vacancies for university professors in Childhood Illnesses had been announced. In almost no time, he prepared for the public entrance exams and obtained the job at the University of Granada (1888). Only one year earlier, Patricio Borobio, who would become a lifelong friend, had obtained the same position in Zaragoza.

University professor in Granada
In Granada he founded the "School for Mothers" in order to educate them on how to take better care of their children. He was alarmed by the poverty and the lack of health education common throughout Spain at that time. He had already suggested that the subject he taught should change its name and become known as Paediatrics. He was known for his social concerns, visiting the most deprived areas of the city, such as the caves of Albaicín, located close to the impressive Alhambra, and he began giving informative talks to its inhabitants about personal and family hygiene. He was behind the creation of the institution that was later known as "Gota de Leche" (Milk Drop) (1891). These centres were attended by healthy wet nurses who donated their milk. This was then sterilised, stored in cold conditions and administered in bottles to the newborns and infants who needed it [6]. The current Spanish "Bancos de leche materna" (Breast milk banks) are their heirs. However, nobody remembers these doctors from the nineteenth century. They were led by Francisco Vidal y Solares (1890) who founded a centre in Barcelona. Years later (in 1904) Rafael Ulecia y Cardona in Madrid would call this the "Gota de Leche" and would then start something similar at their own expense (in Barcelona, Granada, Madrid and gradually widening to the remaining Spanish cities). Andrés Martínez Vargas, aware of the great initiative by Francisco Vidal y Solares, introduced it into his School for Mothers in Granada. On 2 October 1888 he began his teaching activity and in that Facility established a subject which had not existed until then. His lessons on diarrhoea, diphtheria and infant assessments, etc. were followed with enthusiasm by his students. He developed and published some perimetric and pedi-barometric charts: "Tabla pedibarométrica como directora de la lactancia y profiláctica de la mortalidad infantil" (Pedi-barometric table as a guide to breastfeeding and preventing infant mortality). He gave some lessons on the "Introduction to Paediatrics", reinforcing his idea that the subject should be named in this way [7].

Initiative to create a ministry of health
One of his most famous speeches was given at the Commemorative Session of the 150th Anniversary of the Royal Academy of Medicine, held on 29 December 1920.
This speech was entitled "The Ministry of Health in Spain" [9]. He began his speech by noting that this Academic Corporation was older than the ones in London and Paris.

His journal and social concerns
We now go back to 1900 when he founded the scientific journal "La Medicina de los niños" (Medicine for children), in which he, along with other authors, published countless articles until 1936. Many of them are cited by the author in numerous published books and talks. The Spanish civil war put an end to this scientific journal, as it did to all of them [2,7].
He spoke French, English and German and had a good grasp of Russian. This allowed him to be the main Spanish scientific ambassador in many conferences and meetings of all kinds.
There is a record of more than 300 articles published and signed by Andrés, many of them in English, French and German. He collaborated with "La Vanguardia" (Barcelona) and other newspapers, producing another 500 informative articles on aspects of hygiene, disease prevention, child care and care for mothers. Some of them can still be found on the Internet [2].
Deeply concerned about the lack of health and general culture in the majority of the population, he organised and played a leading role in "La Universidad Popular" (The People's University-1902), where on Sunday mornings he would offer free informative talks to the most disadvantaged people in Barcelona's industrial belt. His obsession was to improve the level of education. Other notable scientists such as Odón de Buen from Zaragoza also took part. Not content with this initiative, he imported the idea of the German "Kindergarten", so that working mothers would have places where their young children could be looked after and breastfed by their mothers. In short, he was the promoter of the first Spanish nurseries. At the same time he fought for working women to be given enough time to breastfeed their children and for them to be fed [1, 2, 6, 7, 10].

His relationship with doctor Julio Comby
In 1896, he translated the Treatise on "Enfermedades de la Infancia" (Childhood Illnesses) by the famous French physician Julio Comby [11]. The copy I have read belonged to Dr Alfredo Cebrián. The quality and depth of what is written is of the highest level for its time. Interestingly, Andrés added and published footnotes containing many extremely valuable personal observations, notes and explanatory comments, along with contributions from other foreign authors. Dr Comby wrote about breastfeeding: "Natural breastfeeding should be continued for sixteen to eighteen months, while there is no problem for the mother, since there can be none for the child during this time; on the contrary, the longer breastfeeding continues, the stronger the child will become. It shall be exclusive in the first eight or ten months; only from that age may the child be given some easily digestible foods, such as rice flour, tapioca.... They must not be given wine, vinous water or coffee; milk must be their ordinary beverage, not only during breastfeeding but also long after weaning...". Doctor Cebrián wrote a footnote in pencil: "Dr Martínez Vargas thought the same in his recent speech at the Ateneo" [11].
In the chapter on diphtheria, the historical quotations from Andrés highlight the ignorance that existed about Spanish medical history on this and other topics. Martínez Vargas claimed that the diagnosis of tuberculous meningitis was very simple. Martínez Vargas advised that after carrying out the lumbar puncture, the cerebral spinal fluid should be placed in a test tube and kept for one or two days at room temperature. At the end of this time, a "little cloud" appeared at the top of the liquid. He stated that in this "little cloud" it is very easy to observe microscopic Koch's bacilli. This "little cloud" is a fibrin network in which the bacilli are concentrated, and these can be identified quickly and safely. He may not have been the discoverer, but he spread the word in Spain. This method has been used by the signatory in the cases of tuberculous meningitis attended and it has never failed. The problem of how to rapidly diagnose tuberculous meningitis was solved more than one hundred years ago, but has been lost to current generations. It would be a wise move to recover it [12].

Interest in basic school education
In 1905, he published his "Botiquín Escolar" (School First-Aid Kit), in the La Escuela Moderna (The Modern School) publications. It was a small manual which outlined the most common problems faced by children during their time at school [14]. It has 14 chapters and consists of everything required to provide assistance to pupils as and when needed. It was priced at 0.50 peseta centimos. For the first time the manoeuvres for basic cardiopulmonary resuscitation were explained, through text and drawings, and it advised that children who have suffered a blow to the head, suffering from mild concussion, should be allowed to sleep, against popular belief, and said that placing a coin pressed against the "bump" was not appropriate. It is written with a lot of common sense.

Typhoid fever
Of great interest is "Tratamiento de la Fiebre tifoidea con el Suero.

Criticism of the Spanish situation at that time and his proposals
In 1918 he gave the Inaugural Address at the solemn opening of the Academic Year before the Faculty at the University of Barcelona. Its title "In defence of race", may be viewed as controversial in the eyes of modern readers. However, its content is extraordinary and shows the protagonist's social concerns [16]. Once again his personality can be seen from the reasoning and the energy that shines through. "The older I am, the more I feel the obligation for every citizen to yield to their country and society all the fruit of their experience and their worth, as cooperation in creating the national heritage and as a fair return for the culture with which the nation supported their youth, educated them and prepared them for social action…To my homeland I offer my musings, my work, and some procedures that, if put into practice with great perseverance, will be able to improve our children, our men and put the Spanish nation on a level with the most cultured nations" Andrés demonstrated his pure love for Spain, an aspect that a part of the Catalan nationalist bourgeoisie did not accept. However, many of the social, human and scientific initiatives were of particular benefit to Catalonia. After reading many of his texts, I have come to the conclusion that he was a person of deep religious belief, who had a conservative nature but very advanced social ideas for his time. This dichotomy makes him an even more interesting figure. His pioneering initiatives in human affairs, his boundless dedication to the most disadvantaged, defending the rights of women and children, and of the workers, are examples of this. He did not like what he saw and experienced in Spain, so he fought against it to improve its position. He was conservative in some ways, but extremely progressive in everything social. Multilingual, with people skills, intelligence, a lucid mind that accepted and adopted ideas, a way with words and a gifted writer, researcher, innovator, tireless worker, risk taker, a brave man, interested in everything and everyone, with his own ideas, dedicated to children, families and his beloved Spain and Catalonia, which he fought to improve: that was Andrés.
He continues: "Over recent centuries Spanish society has ignored the regressive reality, living in a continuous paradox with a superficial appearance of strength that concealed a weak interior, with no resistance or austerity; we thought we were invincible until this was tested...but the summer of 1898 came and the country emerged from its historical party to face a surprise: with the disaster the nation lost over half its territory and all its legendary prestige. Since that moment all lips, all speeches, and all printed pages have been full of cries of great pain and an intense national crisis with a strong yearning for improvement has been revealed. Our rulers, the ones who must fix this problem, have sharpened their wits devising a more or less sonorous phrase as a remedy for everything, with no decisive action; one after another they have limited themselves to squeezing the lexicon to create new words that by dint of repetition have fallen into vulgarity and blandness... and with this policy of phrases twenty years have passed aggravating the problem…". These phrases, pronounced in 1918, have also not lost their validity when looking at the situation today. He summarised the Spanish situation at that time: famine, basic lack of culture, lack of hygiene, little importance placed on a child's life, growth deficiency in the Spanish in comparison with the Europeans, the terrifying infant mortality figures already explained previously, multiple authorities that make the country ungovernable.... He wrote something that is very curious but true: "We physicians who help children know the great value of the relationship between an observant mother and the manifestations of a disease in their children, as on many occasions they have given us half the diagnosis".
He strongly argued that the basis of the recovery of Spain was in schools, food and healthcare [16]. He listed the needs of children and adolescents according to age. He proposed the creation of an "Ethnocultural Commission", along the lines of the local and provincial boards of education. He spoke of his Child Protection Policies, established in Lleida, through which parents signed a commitment to do their utmost to keep their children alive until they reached the age of one, for which they were financially rewarded. "We must put an end to the laws appearing in La Gaceta and not regulating our actions... no child should leave school until they are at least 12 years old. If they show their skills they should be rewarded with State or private scholarships… a country that wastes more than 2, 000, 000 pesetas in horse racing and quadruple that in bullfighting should not find it difficult to organise a loan of 30, 000, 000 for schools and scholarships...the prosperity of a people depends more on its education system than on its institutions or government. To fulfil this duty, there is no need for new laws, new agencies, newly appointed civil servants, or financial sacrifices: the will to achieve it and to organise the resources already there is enough." One would think that he was writing about modern-day Spain. Due to extension problems it is impossible to say what he thinks about teachers. One hundred years ago he was already arguing for what is currently required: vocation, knowledge, ability to teach, observing the behaviour of children even in the playground, treating them according to their characteristics, and he concludes by saying that these are the basis of the educational system. This speech is so rich in concepts and development that it deserves a chapter of its own [16].

In France during the great war
His curiosity about everything and everyone took him to France during the First Great European War (1914)(1915)(1916)(1917)(1918) and it was there that he wrote the book "Mi visita al frente Francés" (My visit to the French front) (1919). The copy I have seen is dedicated to a French friend. It strikes me that, despite being dedicated in his own handwriting and with a business card, I had to unstick its pages with a scalpel in order to read it [18]. In short, the friend never read this book in which he describes very innovative surgical techniques in the treatment of the terrible wounds caused by "mustard gas", shells, burns, etc. His thoughts are full of wisdom. "Humanity will not fully enjoy its welfare whilst peace between the nations is not guaranteed, whilst no restrictions are placed on the excesses of a dictator, whilst a kind of patriarchy for universal balance is not created, so that when someone ambitious, unruly or crazy wants to disturb it, the whole weight of the rest of the world is thrown at them, to make them back down, willingly or by force. Instead of performing evil, through science, it would be better to live in a state of backwardness, in primitive ignorance. Progress and civilisation must be based on respect for the law and the concept of justice. Brute force must not dominate reason…" As is clear from his words, Andrés was a staunch pacifist and unfortunately these words are still valid today.

His love for Spain and fundamental scientific works
He had good people skills which allowed him to form relationships with his fellow medics worldwide. He was outraged to find that the history of Spanish medicine counted for nothing and was systematically ignored. From this blessed indignation arose articles in various prestigious journals, rightly proclaiming the achievements of our medical science. That is the context in which his reflections on the work of the Teruel-born Jerónimo Soriano appeared; they were written in French for a select journal and were not wasted.  must be considered as the seed for these studies and which constitutes the beginning and foundation of this speciality in Spain and in the whole world". Andrés heralded the man from Aragon and claimed the rightful place that belonged to his illustrious Spanish physician ancestors, unfairly forgotten inside and outside of Spain. The two greatest founders of Spanish paediatrics had been found…350 years later! [1,2,19].  Reading the Treatise is extremely interesting. Andrés is humble, claiming that you can only take on these tasks with maturity and experience. He defends teaching on three levels: theory, practice and the personal monitoring of the children from the Dispensary in their homes by the students. It is moving to read his informative booklet "La salud del niño. Consejos a las madres para la mejor crianza de sus hijos" (A child's health. Advice for mothers to raise their children better). I imagine that at the end of his professional life, in 1946, he wanted to leave a simple and practical legacy for all Spanish families. He writes: "Every mother has the duty to breastfeed her child. Every child has the right to its mother's breast. When a mother is unable to breastfeed her child, she may be replaced by a wet nurse. If the wet nurse abandons her own child to breastfeed another, she commits an offence against motherhood... A life for a life, no innocent child should be sacrificed!". His sensitivity and humanity remain on the record for all time [20]. The table included on the duration of sleep, play and intellectual work for children according to age is very curious. At the age of 7 he recommends one hour of teaching and this increases annually until it reaches eight hours at the age of 14. This makes one think about the children who at early ages are wrongly labelled as being "hyperactive", and "lacking attention", and who over the years adapt to schooling. One might take note, instilling this wisdom in legislators, parents, teachers, professors, psychologists and doctors.

Nipiological institute
I was especially impressed by the description of the "Instituto Nipiológico" (Nipiological Institute) in Barbastro (1916). The name comes from the word "nipios" in Greek, which means "the one who knows nothing, " referring to the early stages of a child's life. Its founder was the Italian professor, Ernesto Cacace, in 1905. The basis of this doctrine is the need to educate parents on the basic aspects of child care, education, health and nutrition. I do not have the slightest doubt that the choice of Barbastro to found it was an offering to his beloved home town, one full of generosity. Another work mentioned previously is "Enfermedades del niño Recién Nacido" (Diseases in the newborn child) (1941), one of the first books written specifically about the subject and considered the foundation of Spanish Neonatology.

Prologues in various books
He wrote the prologue for many books on different subjects. In "La voz humana" (The human voice), he wrote about the need for children and young people to be taught to correctly use their voices, to avoid undesirable consequences, aspects that were personally dealt with in a Course at the Faculty of Medicine. He therefore anticipated Speech Therapy. His love of music in general, and opera in particular, made him talk about three tenors who were leading stars in the nineteenth century: Enrico Tamberlick, the favourite of Queen Isabel II of Spain, Julián Gayarre and Antonio Aramburo [21]. The latter had his voice preserved in the wax cylinders of the time, once retired from the stage. However, he showed his preference for his countryman Miguel Fleta, an exceptional tenor who lived a very short life (he died at 39), but who has bequeathed various examples of unrivalled art for posterity. In another prologue [5], he congratulated the author's father, a pharmacist, for his bravery in defending the freedom of citizens to choose their pharmacy and for having founded, along with his son, some laboratories that were prestigious in their day and which freed Spain from its pharmaceutical dependence on other countries. One anecdote about his interest in music is the event involving the famous Italian tenor Mario del Mónaco in his début at the Gran Teatro del Liceo in Barcelona. Del Mónaco, very young at that time, did not convince his audience who started "hissing" him. Andrés, now elderly, went backstage to greet him, encouraged him and predicted a career full of triumphs due to his powerful and exceptional voice [1]. He told him that at his age he knew a lot about these situations of apparent failure and that he was sure it would serve to drive the tenor on. He was right, and Mario del Mónaco became one of the best dramatic tenors in the history of opera. His revenge was to not return to that stage for a decade. When he did return it was only as a result of a spectacular financial offer. The impression one gets when looking at the work of Andrés is of his interest and curiosity about medicine, art, humanism, and sociology, his love for children and his desire to serve Spain, his wish to not only improve health care levels but also help society as a whole advance [22].

The 1st spanish congress of paediatrics
The 1st Spanish Congress of Paediatrics, held in April 1914 in Palma de Mallorca as a result of his initiative and under his guidance, was a success in terms of many of his professional concerns. It was attended by more than 300 specialists from around the world [7,[23][24][25]. With this Congress, Paediatrics was consolidated as a speciality. It dealt with various issues relating to Childcare, such as "Insufficient lactic secretion", "Treatment of the umbilical cord", "Breastfeeding and Milk Drops", "The mother's code", the latter being addressed by our protagonist. Issues relating to medicine were also addressed with, among others, the following papers: "Childhood tuberculosis", "Vaccinations", "Dyspepsia" and "Leishmaniosis". Issues relating to Child Surgery were discussed, highlights including the areas of "Scoliosis", "Congenital dislocation of the hip", "Congenital muscular torticollis", "Spina bifida", "Otitis", "Burns" and "Femur fracture". The issue of school hygiene figured prominently in the congressional sessions. Aspects relating to physical education and mental deficiency were studied. In the inaugural speech, Martínez Vargas explained the problem of infant mortality. In Spain at that time, for every 100 deaths, 45.53% were children from nought to ten years old. Motivated by this situation he wrote: "The preferential attention dedicated to children, the desire that exists everywhere to protect their lives, to make them healthy, strong and happy, to help them avoid cruel punishments, and to lighten the effort needed for their instruction, is a modern and surprising initiative: How have so many centuries been allowed to pass without caring for children and how have we had the indifference to see them die in numbers? In view of today's pressures, one might say that society, remorseful of the neglect of children until the end of the last century, is now hastening to make up for lost time, to recapture the abandoned beneficent trenches". But Martínez Vargas was also worried about the serious problem at that time due to the reduction in the birthrate. As a result, decades before other authors, he presented a series of measures that had to be implemented for improved parenting and better education. Firstly he discussed preconception childcare and said that "one of the measures would be the medical marriage license, or in other words, eugenic marriage". Here we see a glimpse of genetic counselling, even at the beginning of the twentieth century. He later advocated embryonic and foetal childcare, which saw the start of Prenatal Medicine, arguing for all kinds of care that the mother should receive from the moment of conception, insisting on the need for joint medical care for the pregnant woman and the unborn child. His interest in the care of pregnant women is shown when he writes: "The working woman, who has to split the hours in the day between the factory and the home, has two great enemies to the strength and vitality of her child, namely excessive work and intoxications…, all those women who work tirelessly and are not adequately nourished give birth to children who weigh 300 grams less than others who enjoy rest and relaxation". He was also worried about single mothers: "The helplessness of these mothers is a frequent cause of infanticide. It would be better, instead of wasting time in boards or meetings, to organise an asylum or shelter suitable for this pressing social need, where the mother could care for her child and later it could go to a nursery or preschool and the mother could return to the heart of society without boasting and without intimidation". He insisted on the need for the government to oblige employers to install rooms in their factories where women could attend to and look after breastfeeding children, giving them the rest time needed. He anticipated current social advances by decades. He argued that before giving bottles of formula milk to children, the mother should be examined and provided with enough food to be able to breastfeed. He refused to accept that formula milk could replace a mother's milk. He rejected the idea that there were illnesses caused by children's drool, or that teething provoked fever, diarrhoea or bronchitis. The minutes and papers from the congress are a monument to the paediatrics of the day. Martínez Vargas collaborated decisively in writing the conclusions, among which the highlights include those regarding childcare and child protection by the State. He argued that this must distribute the mother's code so that its advice could be followed, prohibit contraception propaganda, promulgate the law on rest for pregnant women, giving them two months' rest, stimulate the spreading of child protection policies, encourage breastfeeding, control the industry "originated around wet nurses" and that of the manufacture of bottles, reward families with more than three living children, impose a tax on celibacy, in the Teaching Schools child care should be explained, minors should be protected through the appropriate laws…" Protect children for being the joy of every home, the comfort of old age…the vitality of the nation…Without them nations would disappear"

The encounter with doctor Fidel Pagés Miravé, discoverer of the epidural anaesthetic
There is a chapter of the life of our protagonist that demonstrates his future vision. Andrés Martínez Vargas suspected that this discovery would revolutionise the world of anaesthesiology. He also agreed with Fidel Pagés that it could be applied to women during childbirth. Today it is known as Epidural Anaesthesia. Fidel Pagés Miravé is not sufficiently recognised, either in Spain or internationally, despite his brilliance [24]. The history of his discovery, of the alleged claim by another foreign physician to have invented this technique, his short life which ended in a fatal car accident, and his scant subsequent recognition, require a specific article. Officially he is considered the discoverer of the epidural anaesthesia.

Conclusions
This information about Martínez Vargas, despite being the result of reading and analysing most of his work, is not exhaustive and may be supplemented.
The impression one gets when looking at the work of Martínez Vargas is of his interest and curiosity about medicine, art, humanism, sociology, his love for children, his desire to serve Spain, and his wish to not only improve health care levels but also help society as a whole advance.
At his death the following was written [10]: "He was extolled and widely acclaimed… He also knew what humility, intrigue, ingratitude and slander meant… A magnificent professor, an exceptional physician and a terrific man… He lived for his three great ideals, science, his homeland and children" I firmly believe that Andrés Martínez Vargas deserves the recognition of his countrymen and the scientific world, given the interest of his works and the wonderful complexity of his character.
There is yet to be a doctoral thesis or an exhaustive study made about his passionate life and his vast works.