I noticed Carl Bixby’s 40-year-old hands first, a strange focus for me since I usually find myself immediately drawn to a patient’s eyes: the downward gaze of depression, the frenetic glances of mania, the hypervigilance of psychosis. But these hands, erupting from the red flannel sleeves of his shirt, commanded my attention. They were too big for the rest of the man, even though he was big himself. Thick calluses stood out like cat’s pads amid webs of crevices edged with grease. Dried blood lined new scratches, and numerous scars marked the old. They were strong hands, I thought to myself--well-worn rather than worn-out. They were the kind of hands you’d pray would reach for you if you were drowning. Nothing fragile about them. Grab on as hard as you like. Just as I convinced myself to search the man’s face, he dragged my attention back to his wonderful mitts, slapping them on his knees twice to herald what he was about to say.

I’m broken, he told me. His hands went up to his head. Up here. My brain. Somethin’s broken inside. His thick fingers spread through his long but perfectly trimmed red-brown beard. Suddenly he looked beside himself with grief.

No other patient has ever come to me with a direct complaint about his or her brain. Whatever the role of disturbed brain chemistry or anatomy in producing psychiatric symptoms, the usual view of a sick body part--as in, My leg hurts!--is generally absent. The self may feel injured, the world may appear changed or bizarre or hostile, but the brain, under cover of its own pathology, almost always escapes anything more than vague suspicion.

I looked him squarely in the eyes for the first time. The room seemed to close in around us as he looked back at me--no, stared back at me, his eyes locking on mine and not letting go. I noticed that he hardly blinked. He leaned forward in his chair, as if to see what I had to say.

Your brain is broken? I asked.

Gear stuck, I figure. He pointed with one finger at the crown of his head, then let his hands relax on his thighs. Gummed up. Has to be, seein’ as how I can’t keep up at work anymore. The boss is about to fire me.

What sort of work do you do?

I work for the railroad, he said, still holding my eyes hostage. He had not looked away once. I’m a mechanic. I care for the trains--anything goes wrong with the engines, which something always does, I fix it. Course an ounce of prevention is worth a pound of cure. I keep those babies greased and oiled like race cars.

What’s the problem with that? Why would your boss have any reason to get rid of you? I already had my own suspicions. Five minutes into the evaluation, I felt weighed down by Carl’s intense gaze. It was almost claustrophobic. Having him around for the whole day might be unbearable.

I did real good for ten years, he told me. Better than good. I was one of the top ten mechanics in the whole company. Then, ten, eleven months ago--say November, maybe early December--everything started to change.

The changes, Carl explained, felt wonderful to him. He found himself increasingly drawn to the trains under his care. His social life and hobbies paled in comparison to the lure of the engine. He could work happily for 12 or 14 hours straight, sometimes even through the night, fine-tuning a single cylinder or tracking down the source of a subtle vibration.

At first his supervisor was impressed with Carl’s stunning enthusiasm and ability. He brought him tougher and tougher problems and never found him baffled or overwhelmed. Carl worked harder and harder, with abandon. His girlfriend wondered aloud whether he was in love with someone else.

There ain’t no other woman, Carl swore to me. I’ve fallen in love with those cars. The old ones especially. I can listen to one of those babies roll down the tracks and tell which cylinder is bad. I can feel it. Understand?

I did understand--and told him so. I feel it in my whole being when a sentence works. At times my passion for writing, for the rhythm of words, has kept me from everything else and kept me up, happily, deep into the night.

But Carl’s passion, I could see, had begun crossing the line into obsession. I got myself a room directly over where the cars switch tracks coming toward the station, he went on. They slow down to make that switch, then speed up again. So I can hear the brakes, the wheels, the gearbox--the whole shebang--which is why I moved there in the first place. If somethin’s way off, I can look outside and grab the number off the train. I tell you, I’m on top of those cars even when I’m sleepin’.

The supervisor noticed Carl’s list of trains to be repaired was getting longer and longer. He told Carl the engines didn’t really need to be restored to perfection. Gears could slip, just a little bit. Cylinders didn’t have to fire with musical precision. Even a squeaky brake here and there was acceptable. He didn’t want Carl spending three days perfecting a single engine when there were dozens needing attention.

He says it don’t matter if there’s a little vibration, Carl complained to me. Well, it might not matter to him, but it matters a whole hell of a lot to me. To him, maybe being a mechanic is just a job. To me, it’s more like a religion. He slumped in his seat. But I can see his side of things too. He’s got a whole railroad to worry about, not just one train. Which is why I’m here. I feel out of line. I want to keep my job. And I want to keep my girl. They’re all I’ve got.

I was tempted to linger with the poetry in Carl’s life--a man smitten with the engine, virtually becoming his craft. There was irrationality in his love, but there was also great dedication and undeniable beauty. In a computer age that tends to denigrate the value of labor and minimize the importance of one’s craft, part of me wanted to encourage Carl to pursue his love, whatever the cost. I hadn’t chosen psychiatry as a career in order to talk people out of their passions. Maybe he could work at a railroad museum, rather than a commuter rail. I pictured him as the live-in engineer on the Orient Express. One man. One train. A perfect union.

It was somehow disappointing for me to acknowledge that Carl might be ill, truly broken. I had treated another man, a poet stalled for months perfecting a single verse, who turned out to be epileptic. The electrical storms that cause epilepsy can occur in any brain region, and they can cause a vast array of symptoms, including the dramatic muscular spasms and thrashing known as a full-blown tonic-clonic seizure. But there are apparently some epileptic patients, like the poet--and, I suspected, Carl--who exhibit only changes in personality.

Subtle seizures can cause nearly religious devotion to tasks that would otherwise not command it. This is particularly true when the seizures occur in the brain’s temporal lobes, two wedge-shaped flowerings of tissue sandwiched between the frontal and occipital lobes, approximately at the midline of the skull. The temporal lobes contain portions of the limbic system, a constellation of brain structures that house the most important emotional circuitry of the brain.

While the findings are controversial, researchers have noted that some patients with temporal lobe epilepsy share traits, including preoccupation with philosophical interests, a tendency to write excessively, extreme religious feelings, changes in sexual appetite (usually reduced), and an irksome clinging, obsessive quality called viscosity.

Psychiatrists have also wondered whether an undetectable level of seizure activity might be at the heart of mania, that psychiatric condition marked by seemingly boundless energy, lack of desire for sleep and food, a grandiose self-image, and sometimes, euphoria. Other than the naturally occurring salt of lithium--whose mechanism is unknown--anticonvulsant medications like valproic acid and carbamazepine are the mainstays of treatment.

The Russian writer Dostoyevsky, who had epilepsy, described the emotion he experienced just as a seizure was beginning: You all, healthy people, can’t imagine the happiness which we epileptics feel during the second before our fits. . . . I don’t know if this felicity lasts for seconds, hours, or months, but believe me, I would not exchange it for all the joys that life may bring.

Others have reported hearing beautiful music, reexperiencing childhood memories or seeing luminous visions of God.

Is epilepsy itself, then, always a disease? If we were to uncover every case and treat it, might we lose some of the contributions given society by philosophers, martyrs, and great artists? Could it be that in certain cases there are gains that derive from abnormal electric discharges in the brain? Would I urge artists like Dostoyevsky or Van Gogh toward more well-rounded, less single-minded pursuits?

My suspicion that temporal lobe epilepsy might be responsible for Carl’s heightened romance with his work grew stronger when he reported having been knocked out by a fall off a train platform about a year earlier. Injuries to the head, with resulting damage to brain tissue, can trip the runaway electric circuits of epilepsy.

I met with Carl and his girlfriend. She was a woman in her thirties who worked as a tailor’s assistant. She held one of Carl’s magnificent hands in both of hers and listened nearly as attentively as he while I explained the usefulness of ordering an electroencephalogram, or eeg, a recording of brain activity. The eeg uses a series of sensitive paste-on electrodes, usually placed on the scalp or in the nasal passages, to disclose abnormal electric discharges. If he has this--this seizure problem--and he gets treated for it, will he lose all interest in trains? she asked. Will he still be the best at fixing them? She turned to him. Because, Carl, if that’s what’s gonna happen after you go through all this, you should just forget about that test and we should get out of here. We’ll work things out some other way. Hear?

My throat tightened at the evidence of her love for my patient, her willingness to put herself second to the engine if I could do no better than return her man to her less than he was. What, I wondered, is the neural circuitry of such devotion? With the right equipment would we find subtle seizures flitting across the eegs of people in love?

From what I can tell, Carl’s problem started with his head injury. I paused. The word problem didn’t seem quite right. If seizures started then, the right medicine might bring him back to normal, not less than normal. I held up my own hands. I can’t know for sure what would happen if he took the medicine, I admitted. If he doesn’t feel that it helps, he can always decide later not to take it.

Carl helped us out. No sense not looking, just so we don’t find something, he said. His gaze locked on me. If I got a bum gear, I want it fixed and fixed for good.

Even if it means you lose some of your passion for your work? I prodded him.

You can have a train chugging down the track pretty good, too, but it ain’t much if it got no brakes. I can’t shut myself down now. That ain’t right. I want to keep my job and I want to keep my girl.

Carl underwent the eeg. As I suspected, his tracing showed abnormal discharges in one of his temporal lobes.

Carl seemed relieved by the results. He looked up, as if to inspect his own brain.

How do we get at it?

I told him I would suggest starting carbamazepine, one of the antiseizure medications.

Well . . . he pondered. He laced his fingers together and cracked his massive knuckles. Better get it tuned.

Carbamazepine works only within a certain range of concentrations in the blood. During the next few weeks we adjusted Carl’s dosage until his level became therapeutic. In under four weeks, his supervisor commented that Carl was beginning to keep pace with the volume of repairs again. Within six weeks, the work was getting done--and not overdone.

I got to thank you, Carl told me. I noticed it was easier to sit in the room with him. He looked at me, not through me. He winked and said, I’m back on track.

Back on track. The seizures in his brain were gone. That was true. But there was another part of Carl, I decided, that diagnosed his own life as normal again, in balance. Another patient might have fought against my medicine with all his will. I would have been the enemy of his greatest devotion. What compass in the soul, I wondered, tells a man that his life is what he wants it to be, that he is moving at the right speed, in the right direction?