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James A. Garfield was the 20th president of the United States, and served one of our shortest terms: after being shot by assassin Charles J. Guiteau, he lived over two months before dying in September of 1881. Destiny of the Republic is the story of Garfield’s short presidency. As expressed in the subtitle, it is also the story of Guiteau’s madness and the medical era in which Garfield was unsuccessfully treated. What is left out of the title is the story of Alexander Graham Bell, who worked on a metal detector that was related to his recent invention, the telephone, with the intention of locating the bullet lodged in Garfield’s torso. So, to recap: this is the story of Garfield the President, Giteau the assassin, Bell the inventor, and a Dr. Bliss, who headed up the President’s medical team.

I knew next to nothing about Garfield, although I had a vague sense of his dying journey to the sea, passing by train through crowds of Americans gathered to honor him. I assume I’m not alone in my ignorance; he’s a long-dead president who (necessarily, by virtue of his short service) made no historical contributions sufficient to bring him to a modern layperson’s consciousness. So, I’ll fill in a little more. Garfield is painted in the opening chapters as a very sympathetic man: he did not aspire to the White House, but rather was nominated against his will by a post-Civil-War Republic Party that could not agree on any of the more favored candidates for nomination (Ulysses S. Grant, James G. Blaine and John Sherman). He was humble. In this book, he is a likeable character (more on that to follow).

Interspersed with descriptions of Garfield, his very humble past as a poverty-stricken and fatherless child, and his marriage to Lucretia (“Crete” ), are descriptions of Guiteau. Guiteau is, briefly, delusional. I don’t know what his diagnosis would be in today’s mental health establishment, but he would be diagnosed. He believes he deserves great things and the world owes him; he is a chronic petty criminal, and because he once wrote a speech (never delivered) stumping for Garfield, he believes upon Garfield’s election that he deserves a lucrative posting, preferably to Paris. (One of the hot political issues of this age was the spoils system.) In his diseased mind, Garfield’s failure to honor him becomes a crime punishable by death; and/or it’s God’s will that Garfield be killed; and/or Vice President Chester Arthur needs to be President for the sake of the country, etc. Thus the assassination.

Also interspersed are some of the thinkers of the era. Alexander Graham Bell has just invented the telephone, which although not ubiquitous, is beginning to change communications for some of the population, and will have great future impact; in the meantime Bell works feverishly on that and other inventions. Also contemporary is the British Joseph Lister, pioneer of the concept of antisepsis, or sterilization of medical (especially surgical) equipment. Medical minds of the day did not generally believe in germs, because they could not see them, and practiced surgery on the second patient with the blood of the first still wet on their hands (not to mention pus and general dirt). Lister tried to convince American doctors of the lifesaving power of sterilization, but in the case of Garfield’s Dr. Bliss, failed.

So the action of the story follows Garfield’s nomination, election, and early days in office; Guiteau’s descent into madness, and his shooting of the President; Bell’s laboratory work, including work on a machine to locate the bullet lost inside the President; and the medical community’s thoughts on antisepsis. Dr. Bliss is an unsympathetic character. He successfully bluffs a small crowd of other doctors, several better qualified, and at least one more open to the idea of sterile surgery, out of the White House, taking over Garfield’s care himself. He is imperious, intolerant, and unpleasant; it also turns out that he had the wrong medical ideas, with the knowledge we have now. Garfield suffers in the White House for some two months after being shot, with a bullet lodged near his liver. During this time he is endlessly poked and prodded with filthy fingers and probing implements, deep into his wound. We know now – indeed, they mostly understood upon his autopsy – that it was not the gunshot that killed him, but the massive infection caused by unsterilized instruments. And then, we hear of the First Lady’s mourning, and the trial and hanging of Guiteau. In the epilogue, we also follow Bell, Bliss and Lister through to their eventual ends.

I found this story fascinating, as perhaps is clear from my lengthy synopsis. I liked that Millard sketched the political background of the United States in the decades after the Civil War, the lingering divisiveness of North vs. South, the corruption of the spoils system and the conflict between VP Arthur and Garfield’s presidency. I found the characters interesting, compelling, and real. This history is told relatively briefly and at a quick pace: I think reluctant readers of nonfiction will be pleased, and yet I don’t have reason to think it was dumbed down or oversimplified. Destiny of the Republic is good, readable history for the mainstream reader, and I recommend it.

I do have one concern. Garfield is portrayed in a wholly sympathetic light. I don’t know enough to criticize him; but I’m always suspicious of such a glowing picture of a historical figure. Surely he wasn’t all good? I worry about so much praise, as I said in my review of Team of Rivals.

I really enjoyed getting a glimpse of the medical thinking of this era, which I thought was well handled, although in brief. The conceptual leap to believing in invisible germs and the risk of infection has to be one of the more important in the history of medicine, and I can understand how people like Bliss who thought they knew what they were doing would be skeptical, although it’s hard to sympathize with him in this story of the huge consequences of his skepticism (coupled with his egotism and nasty personality, of course). There was another angle I wish had been explored as well, regarding Bliss’s very imposing nature, the bossiness with which he took over Garfield’s care, and his unwillingness to let either the President or the First Lady choose a doctor or make medical decisions. This is another area of medical practice in which change has occurred much more recently: the authority of doctor versus patient. We’re still working this one out, but today, no doctor would be so likely to barge in and tell the wife of an unconscious man which doctor would be treating him; and if she called in the doctors of her choosing and fired the first, her decision would stand. Now, Mrs. Garfield never tried to “fire” Bliss – it wasn’t done. But that’s my point: the concept of who holds the power in that relationship, doctor vs. patient (& family/caregiver) has changed drastically. As someone who works in a hospital setting with patients and family members, not to mention some of the decisions I’ve seen made in my own family, my mind jumped at this part of Garfield’s story. He had no advocate to protect him against the failures of the medical establishment; no second opinions were allowed; the patient and his family were allowed no part in the decision-making process. Not only would antisepsis have made the difference to Garfield, but, I submit, patient advocacy and empowerment would likely have made a major change as well: if he had still died, at least he might have been much more comfortable, and I think quality of life even at the end of life should not be discounted. If I had written this story (with my perspective as a medical librarian), I would have added this facet to Garfield’s story as well.

Minor quibbles aside, I really enjoyed Destiny of the Republic and found it an easy, engaging, quick read that I would recommend to anyone. The audio production, read by Paul Micheal, was entertaining and gave the varying voices to the story that I think it needed. Well done.

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