PDF Summary:The Black Angels, by Maria Smilios

During the early-to-mid 20th century, tuberculosis ravaged poor and marginalized communities, particularly in places like Harlem where Black residents died at nearly three times the rate of white residents. In The Black Angels, Maria Smilios examines the history of tuberculosis treatment at Sea View Hospital, a municipal facility that served as both a treatment center and research site for the city's poor.

Smilios traces the evolution of tuberculosis treatments—from experimental surgical procedures to collapse infected lungs to the eventual discovery of isoniazid, the drug that cured the disease. She also highlights the experiences of Black nurses at Sea View who fought against racial discrimination while caring for tuberculosis patients, and explores how their activism contributed to broader changes in nursing and healthcare.

(continued)...

The outcome was a straightforward device that involved placing a needle into the pleural cavity, a narrow gap between the membranes enveloping the lungs. When the needle punctured the cavity, the mechanism injected nitrogen via a tube, which inflated it with air and collapsed the lung. With no oxygen, the TB bacilli would starve and die, halting the spread of disease. It proved effective, and Forlanini's patients quickly started getting better, which led to his success and the development of a new technique formally named "artificial pneumothorax."

(Shortform note: In The White Death, Thomas Dormandy clarifies that the artificial pneumothorax didn’t literally starve the TB bacilli of oxygen. Instead, it forced the thin-walled cavities in the lungs to close, which caused them to scar and made it harder for the bacilli to grow. He explains that the lungs are like sponges, and the TB bacilli are like water that soaks into the sponge. The artificial pneumothorax squeezes the sponge, forcing the water out.)

Once the surgery became standard practice and used local anesthetic, nurses dealt with a variety of side effects. The injected air frequently accumulated in the armpits, causing intense gas, swelling, and extreme pain in the arms that persisted for seven to ten days. Afterward, it started leaking from the puncture wound. As patients moved around, whether they were resting, smoking, speaking, or playing cards, they released air, which produced peculiar noises like whistles, toots, or hisses. After it dissipated, patients went back for a "pneumo-refill."

(Shortform note: The chest wall and the axillary (armpit) region form a continuous compartment, allowing the gas to drift upward. The axillary region is highly compliant, meaning it can expand easily to accommodate the gas. The gas is under pressure, so it naturally seeks to escape through the path of least resistance, which is the channel it entered through. This is why the gas eventually leaks out, necessitating a "pneumo-refill.")

Some underwent more than a hundred instances of air being added back. While numerous people praised the procedure for its fast and effective outcomes, there were plenty of critics—doubters who thought physicians rushed the needle insertion, which could rupture membranes, cut lungs, and pierce the heart. Awake patients experienced seizures, shock, fainting, and at times, died. There were additional complications like chest wall hemorrhages, fluid accumulation, subcutaneous air, neuralgia, skin infections, and pleurisy, which is the inflammation of the membranes encasing the lungs. People claimed Forlanini's invention was "the deadliest tool doctors had ever been given." Despite criticisms, its popularity continued to increase. In 1930, Sea View physicians carried out three thousand pneumothorax surgeries annually, a number that rose to more than 30,000 by 1935.

(Shortform note: The complications of pneumothorax surgeries were often due to the repeated addition of air into the pleural cavity. Each time air was injected, it could cause the delicate pleural tissues to stretch and tear, allowing air to escape into the surrounding tissues. This air could then track along the chest wall, causing subcutaneous emphysema, or enter the bloodstream, leading to air embolisms. The repeated trauma to the pleural tissues could also cause inflammation and infection, further complicating the patient's condition. In some cases, the air could accumulate in the pleural cavity, causing a tension pneumothorax, which could compress the heart and major blood vessels, leading to shock and even death.)

When artificial pneumothorax therapy was unsuccessful, doctors turned to more invasive surgical methods: they would puncture, pierce, and cut into flesh, nerves, and diaphragms, and fill chest cavities with wax packs. These all paled beside thoracoplasty. In this two- or three-stage procedure, surgeons aimed to change the thoracic cavity—the chest's primary structure that protects the heart, lungs, liver, and diaphragm—to create a permanent collapse of one lung.

(Shortform note: By the time Sea View adopted thoracoplasty, it was already a standard operation. In the early 20th century, European tuberculosis centers had refined the procedure, and their surgeons trained colleagues worldwide. This international exchange of knowledge helped standardize thoracoplasty techniques and spread them to sanatoriums like Sea View.)

The surgeon made a long cut beginning at the bottom of the neck, moving downward along the shoulder blade, and ending under the armpit, then they reached inside the body and removed rows of ribs—sometimes as many as eight or nine. With the ribs removed, the pleural cavity—which holds the fluid essential for optimal lung function and lubrication—is disturbed, leading to lung collapse. With the lung now collapsed and without air, the germs would start to be deprived of sustenance and perish. Despite its effectiveness, thoracoplasty frequently caused a series of problems: cardiorespiratory issues, blood poisoning, bleeding, pleural tears, post-surgical shock, infected wounds, and anoxemia, a condition of reduced oxygen levels that could be fatal. Most of these complications frequently affected people who were too ill and fragile to recuperate from such an extreme surgery.

Thoracoplasty Left Many Patients Deformed

In The White Death, Thomas Dormandy adds another complication to this list: the severe deformity of the chest wall and spine that many thoracoplasty survivors were left with. Dormandy explains that thoracoplasty, even when counted a therapeutic success, was “a mutilating operation” that left countless patients with a permanently distorted trunk: the operated side of the chest collapsed in on itself, the shoulder on that side riding high and stiff, the spine bent into a lasting scoliosis, so that many survivors spent the rest of their lives visibly misshapen and functionally crippled by the resulting thoracic and spinal deformity.

The Black Angels: Labor, Racism, and Progress at Sea View

Smilios highlights how Black nurses at the Sea View hospital fought against racial discrimination. The NACGN was established in 1908 to advocate for equality in health care, higher professional standards, and robust leadership for African American nurses. The organization made some progress, but by 1930, it was struggling due to insufficient funds, a director who received a salary, and political and social connections. Black nurses experienced discrimination from their white counterparts, who thought they were inferior and inclined to challenge authority. White nurses often quit rather than work with or take orders from Black nurses.

(Shortform note: In Black Feminist Thought, Patricia Hill Collins introduces the concept of the “outsider within” to describe the unique perspective Black women gain when they work within institutions dominated by white people. This position allows them to see the inner workings of power structures while remaining marginalized. Collins argues that this dual awareness enables Black women to develop a critical consciousness about how race, gender, and class intersect to maintain systems of oppression. She explains that Black women who labor inside institutions controlled by dominant groups often occupy an “outsider-within” position, and this partial inclusion combined with continued marginalization gives them a distinctive angle of vision from which they can grasp how power actually operates, discern the contradictions between an institution’s stated ideals and its everyday practices, and develop a critical consciousness that challenges intersecting structures of race, gender, and class domination.)

The NACGN president, Mabel Staupers, opposed the military's limits on Black nurses and the fact that they were restricted to caring for POWs. She met with Eleanor Roosevelt, the First Lady, who pressured the military to accept more Black nurses. The military eventually did away with quotas and included Black nurses, officially ending segregation. Staupers hoped the ANA would follow suit, but they declined to change. Black Sea View nurses also fought against discrimination. They discovered signs reserving the eating area for whites and went on a daylong strike. The incident received negative press, and the notices were removed. The city stated that Black nurses would now be admitted to nursing schools and hospitals, and the initial Black nurses began working at a previously all-white hospital.

The Myth of Military Integration

The idea that relaxing quota limits for Black nurses led to a desegregated military is a misconception. Archival research shows that Black nurses were still assigned to segregated hospitals and living quarters for years after the policy change. The military's decision to ease quotas was a response to public pressure, not a genuine commitment to integration. The military's actions were more about appeasing critics than creating a truly integrated nursing corps. The military's approach to integration was gradual and often met with resistance from within the ranks. The military's slow progress on integration reflected broader societal attitudes toward race at the time. The military's experience with Black nurses during World War II laid the groundwork for future integration efforts, but it was far from a complete victory. The military's handling of Black nurses during World War II highlights the complexities of racial integration in American institutions.