John Fleischman, author of the morbid yet fascinating book Phineas Gage: A Gruesome but True Story About Brain Science, answered questions posed by students.

What made you want write a children's book about this gruesome topic?
In September 1998, I went to the little town of Cavendish, Vermont, where they were having a festival to mark the 150th anniversary of Phineas's accident. Down in the village, they were having a country festival with fresh apple cider, folk music, handicrafts, and so on. Up the mountain at an empty ski lodge (it was September), they were having a medical symposium with neurologists, psychologists, surgeons, and other scientists from Europe, Japan, Australia, and the US. As part of the festival, a Harvard neurologist had arranged to borrow the skull and iron of Phineas Gage from the Countway Library of Medicine so it could be exhibited in the town hall for just one afternoon. Then it would go straight back to Boston. The Countway Library insisted that Phineas travel to and from Vermont in a private limo with his own museum curator to look after him. In Cavendish, the skull was locked in a glass case with the tamping iron on a table next to it. When I went to see Phineas, the line of townspeople and tourists was out the door and around the corner.

I took my first look at the skull of Phineas Gage and his famous tamping iron. And then I noticed the kids. First there were lots of kids. The Cavendish elementary school had done a unit on Phineas, so many of them wanted to see the real Phineas but there were kids there that day from all over Vermont and elsewhere. Everyone had the same first reaction: Everyone looked at the hole in the top of the skull and winced. Then I noticed that the kids could be divided into two groups. One group looked, winced, and turned away eyes shut. They couldn't get away fast enough. The second group of kids took a look, winced, and then tried to push their noses up against the glass. This second group really wanted to see exactly what had happened to Phineas Gage and some of them didn't want to leave until their parents insisted that they were holding up the line. I wrote Phineas Gage for this second group.

How did you first become interested in Phineas Gage?
In 1998, I went to a festival and medical seminar in Cavendish, Vermont, for the 150th anniversary of Phineas's accident. See my answer to the previous question "Why a kids book?" Also when I was a kid, there was a cartoon in the Sunday newspaper called "Believe it or Not!" The story of Phineas Gage was in that cartoon although I can't honestly say I remember seeing that episode. I went to Vermont because the festival caught my attention and I had some useless piece of information floating around in my brain about a man who truly had a hole in his head. When I was researching the book, I saw a reprint of the Phineas Gage "Believe It or Not!" cartoon. "Believe It or Not!" had it all wrong. The drawing showed Phineas with the tamping iron stuck permanently in his head. He would not have lived another 30 seconds, let along another 11 years that way (the slightest wiggling of the iron would have cut the tiny blood vessels in his brain). Besides, whenever I told people about Phineas, they always seem to have more questions. Phineas raises a lot of questions.

How/why did Phineas survive such a terrible accident?
It was luck, either good luck or bad luck depending on how you look at it, but that's up to you to decide. As one doctor told me, Phineas should have been dead for at least five major reasons. Even today, the odds against surviving an injury that pierces the brain are stupendously high. Phineas survived 150 years ago. This was before doctors even understood about bacterial infection let alone about how the brain is organized. Phineas's "luck" was in the precise path the rod followed as it shot through his frontal cortex. He was also lucky in that he was young and very strong. Finally, Phineas was lucky in that Dr. Harlow washed his hands before cleaning up and bandaging the wound.

Are there any films or movies about Phineas Gage?
A recent episode of the PBS documentary series "Scientific American Frontiers with Alan Alda" had a segment about Phineas as part of a program about brain research. Alda was there when they took the skull of Phineas Gage out of its display case in the Countway Library and carefully wheeled it across the hospital next door, where it was sent through a CAT scan machine. The doctor doing the CAT scan wanted to test a new theory on how Phineas's skull was able to survive the impact of the tamping iron. This experiment took place after I finished so it was news to me too. Check the PBS Web site under "Scientific American." The episode was aired last fall. As far as I know, no one has ever made Phineas into a dramatic movie or play. (Movie producers are welcome to contact me, but I'm not sure what a screenwriter would do for a love interest in this story.) There used to be a rock band called "Phineas Gage" but I think they broke up.

Are you thinking about writing any more science books for kids?
I am trying to find a story about DNA and genomes that is as good as the story of Phineas Gage was about the brain. It's hard. The "heroes" of genome science are mice, fruit flies, worms, and yeast. These animals are telling us so much about how humans are organized, but they don't grab our attention the way Phineas did. I'm also working on a nonscience book. It's a true story about two boys who grew up in the same neighborhood, were in the same fourth grade class, and then flew in the same bombing missions over Germany during World War II. Afterward, they went home to the same city but never met. They didn't become friends until they were old men at the same pilots reunion. One was white and one was black. Today they go around together speaking to school kids about why race made all the difference when they were young and why it shouldn't anymore.

What kind of research did you have to do to write the book? Had you studied brain science before or was it all new to you? How long did it take to gather all the information?
I went to a small liberal arts college and studied English. This was so long ago that even if I had majored in biology or anatomy, everything I would have learned would be completely out-of-date today. I started as a newspaper reporter. Every day, my editor would send me out to write about something about which I knew next to nothing. Reporters get to ask a lot of questions, even stupid questions, until they knew enough to write the story. I loved that.

Eventually, I worked for newspapers, a radio station (very briefly), and lots of magazines. I found that I liked writing science stories for magazines, even if I knew next to nothing about the particular story when I started. Scientists usually focus on a single field of knowledge; in fact, they tend to focus on one tiny patch within one small field. Most scientists don't expect outsiders (including scientists from other fields) to know much about their specialty. Most don't mind answering questions, even stupid questions, about their special patch, as long as the questioner seems genuinely interested. As a magazine journalist, I usually had to go home and write something about this bit of science. I needed to know enough to make sense of it for my editor. Otherwise, I would have to go back and ask even more questions. I was interested in all sorts of science including melting glaciers, animals going extinct, excavating ancient cities, and the search for extraterrestrial intelligence (which the experts call SETI). Eventually I learned that it was easier to write a second story about the same scientific field than it was to learn about a third science from scratch. You already had some idea of the basics so I began to write more about biology and medicine topics. These are huge fields so I also began to read more background material. One summer I took a special lab course for journalists who wanted to write about cell biology.

That's about where I was when I went to Cavendish, Vermont, to attend a festival and medical seminar in honor of the 150th anniversary of Phineas Gage's famous accident. It took me about two months to ask enough questions and read enough background to write a magazine story for grown-ups. It took me another year, working on and off, to figure out what else kids would need to know about Phineas and then to write the book. It took me another six months to finally round up all the pictures and illustrations for the book. Now I know something about brain science but chiefly how much scientists don't know. But scientists and science writers will go on asking questions.

In your book, you talk a lot about how science has changed over time since the rod went through Phineas's skull. Do you think it's possible that in the future science may change again so that what we think about Phineas now turns out to be wrong or incomplete?
Absolutely. Ask any neuroscientist or physician and the first thing they will tell you is how little we do know and how much we don't about the brain. We have amazing, new technologies that can scan a living brain. We've just decoded the complete DNA text for human beings that includes all the instructions for building and operating the human brain. And yet scientists say we still only have the outline of how the brain really works. Your brain and spinal cord are thought to contain about 10 billion neurons. Each neuron is thought to contain a billion proteins. To work correctly, each neuron has to get the right protein in the right place and the right time. Do the math. A brain is unimaginably complex.

Will future scientists find out that the doctors in Phineas's time who thought you could map brain activity by the bumps on the skull were right? Probably not. Will future scientists see the brain differently than we do? Sure. Will they understand the brain completely? I doubt it. In my book, there's a photograph of doctors performing surgery in 1847. The surgeons are wearing street clothes. We are shocked to see them doing an operation without surgical gloves, masks, drapes, or sterilized instruments. The doctors of 1847 didn't know about bacteria and infection. Today our doctors have all studied bacteriology, operate in strictly controlled conditions, and have powerful antibiotic drugs on hand. Yet infections are still a problem because bacteria have kept up with medical science by evolving into new forms that resist antibiotics. Here's a prediction: in 50 years, you can show a picture of surgeons operating in 2003 to your doctor in 2053. Your doctor will laugh at how little we knew. In another 50 years, your grandchildren can show a picture of your 2053 doctor to their doctor. And everyone will laugh at how little we knew.

Now that you know so much about brain science, are you planning to go into it even more? I mean, do you think you'll do more research about different areas of brain science? It seems like a topic where once you start learning, you want to know even more.
I think it is. One of the things that interests now is why neurons don't heal. So many other kinds of cells in our bodies heal but neurons - in the brain and in the spinal column - do not. There's a huge amount of research going on because it affects so many - people with "neurodegenerative" diseases like Alzheimer's and people with spinal cord injuries (including far too many young people injured in accidents) who face the rest of their lives in wheelchairs. But as I wrote elsewhere in one of these messages, I am always looking for a good story - one with a good character like Phineas Gage - to carry the science along.

In your book you say that after the accident, Phineas seemed to be recovering quickly and Dr. Harlow thought he was trying to do too much. So then he gave Phineas drugs to bring his humors into balance, but the drugs knock Phineas out. Do you think that maybe Dr. Harlow actually prescribed the drugs because he wanted Phineas to rest more and that was the only way he could get him to stay still?
Dr. Harlow was definitely concerned about Phineas's behavior. But you have to remember that Dr. Harlow was trained as a doctor a long time ago. Today a doctor might be more concerned with Phineas's red cell count or the results of his CAT scan. Dr. Harlow was worried about balancing Phineas's humors. The drugs he prescribed - a powerful emetic and a powerful laxative - were not that exotic but they had the desired effect. They knocked Phineas into bed for several days of quiet and rest.

How did you get access to all of Dr. Harlow's writings about Phineas?
Dr. Malcolm Macmillan's book An Odd Kind of Fame: Stories of Phineas Gage (MIT Press, 1999) reprints all the important documents including Dr. Harlow's papers. Go to Dr. Macmillan's Web page for details. Some of these documents may be posted elsewhere on the Web, but Dr. Macmillan's book has everything plus Dr. Macmillan's comments.

I'd read long ago that, as a result of the accident, Phineas found that he needed very little or no sleep, that he worked and read during the evenings. Did you find anything about this in your research?
I read all the firsthand accounts of the accident and his recovery that I could find. (See Malcolm Macmillan's book An Odd Kind of Fame or his Phineas Gage Web site if you want to read them yourself.) I don't recall any direct reports, one way or another, about a change in his sleeping habits.

In the weeks after his accident, Phineas was very sick from the infection around the exit wound in his forehead. When he recovered somewhat, he was described as being very restless. Dr. Harlow had to go out of town at this time, and when he came back, he was told that Phineas had been wandering all over Cavendish at odd hours and in bad weather. Dr. Harlow used some powerful herbal medicine to knock him out and keep Phineas in bed for several days to rest. That's the only section I can recall that talks about Phineas and sleep. If you should find this report that you remember reading about his sleep habits, please let me know.

Do you know if any pictures of Phineas Gage exist, besides the ones of his skull?
Besides the skull, the only known "picture" of Phineas Gage is the plaster head made from his "life mask" when he was in Boston at the Harvard medical college in 1850. In a way, that's better than any drawing or even a photograph. (If Phineas ever had his photograph taken, it's either been lost or the identification has been lost so the picture may exist, only no one knows it is Phineas Gage.) For the life mask, Dr. Bigelow greased Phineas's face, put straws up his nose so he could breath, and covered his face in plaster. When he lifted it off, Dr. Bigelow had an exact copy of the face of Phineas one year after his accident. He used it as a mold to create the "bust" of Phineas that you can see today in the Countway Library at Harvard Medical School. You can see the big scar on his forehead that lines up exactly with the hole in the skull. If you want to know what Phineas looked like, imagine that plaster bust in street clothes and real hair with his eyes wide open.

After doing so much research on Phineas, do you feel like you almost know him now? Do you think you would have liked him if you had really known him?
A great question and one that no one has asked me before. I had to think about it for a moment. I don't have much feeling about Phineas before the accident when he was "normal." Everyone said he was a likeable guy on the job and he must have been good with people to run a big work crew. But I have no idea what he was like off the job, whether he was funny or loud or quiet. I have a much stronger sense of him after the accident. Dr. Harlow said, "Gage was no longer Gage" and it's clear he had many problems getting along. But I think some of the "old" Gage survived. He remained brave and fiercely independent. After all, he worked, traveled, and took care of himself for 11 years afterward. I think a talent with horses is something you have early in life and Phineas seemed to have it after his accident as well. And as hard as it must have been for Phineas to interact with "normal" strangers, he stayed in touch with his family (no small thing in those days) and when he began to feel sick in South America, he traveled thousands of miles to be with his mother and sister again. He died with his family sitting beside him.

I imagine that if I met Phineas on the street, I might not notice anything odd about him (as long as he kept his hat down over his forehead). If I spent a few hours watching him in a clinic or even just sitting next to him on a car trip, I would probably come away thinking that this guy was strange. I think, however, that if I were with him while he was busy with something he liked to do, he'd be good company. I'd like to go for a long carriage or wagon ride with Phineas at the reins. Would he talk or would he be quiet? Would he remember me as a friend the next day? I don't know but I bet it would be a good day's outing.

Why did you include all that stuff about bacteria and infection in the book?
Today doctors can give you a long list of major medical reasons that Phineas Gage should have been dead, either instantly or within days, of the accident. Yet he survived. Surviving a rod through the frontal cortex was amazing enough, but surviving the infection that followed is right up there in Phineas's list of medical wonders. Even today with modern surgical techniques, equipment, and drugs, people still die of "post-operative" infections. Today it's a small percentage of all surgical cases. In 1850, your chances of surviving any kind of major surgery were probably no better than 50-50, chiefly because of bacterial infection. His "surgery" was done by an iron bar, but Phineas dodged certain death yet again when his body defeated those bacteria. I also needed to explain the idea that cells are the fundamental unit of all life. Surgery became a lot safer after Pasteur discovered that tiny animals - single-celled bacteria - caused infection. But the "cell" revolution also swept through brain science. Through the microscope, doctors could see that specialized cells - neurons - were the fundamental units of the brain. Without that discovery, the whole brainers and the phrenologists might still be arguing. So from Phineas and bacteria, you can get to brain cells and Phineas. From cells, you can get to almost anywhere today.

This subject is really gross, but cool! Did you ever get grossed out when you were writing the book? Did anyone ever tell you that you shouldn't have written such a gross story for kids?
Everyone told me that a book about Phineas Gage was too gross for kids, everyone, that is, except my editor at Houghton-Mifflin, Amy Flynn. Amy thought it could be a cool book. She talked her company into publishing it; talked me into cutting out some stuff (it was boring not gross); and talked her designers into using so many different kinds of pictures. The result, I think, is a cool-looking book. Getting grossed-out is a funny thing. If you want to be a doctor, a policeman, or even the parent of a baby (diapers!), you have to get used to "gross" things. And you do. But even doctors can sometimes be grossed-out by things that happen out of context - a surgeon outside the hospital whose child cuts her head badly or a highway patrol officer on vacation who comes upon a terrible accident. (Surprise can make anything scary. That's why in movies, the chainsaw killer or the monster always jumps out of nowhere.)

On the other hand, some people use grossing-out as an excuse for never looking at anything closely. Some companies use gross-outs as a way of making money. When I talk in schools about Phineas, I ask kids what holiday is associated with skulls. Halloween, they say. And what do you do with a skull on Halloween? Scare people, they say. But then I have them feel their own skulls - feel the cheekbones, the ridges over the eyes, and the bump at the back that protects the spinal cord and lets them turn their heads. When it's your own skull, it's not so gross. I did get grossed out once when I was researching Phineas. It was at a medical symposium about brain injuries, and an ER surgeon was showing slides of brain trauma cases he'd treated. At one point, I had to look down. All around me were doctors who'd come to the symposium expecting to see these sorts of slides. They were used to them. After a minute of quiet breathing, I was able to start watching again. After a half hour, I was almost used to them. Sometimes you have to take a deep breath. Sometimes you need someone to explain what you're seeing, but don't be afraid to look for yourself. Don't let other people tell you what's gross.