The Metamorphosis
Authors: Cyrus Abbasian
Journal: BMJ (2007)

“When Gregor Samsa awoke from troubled dreams one morning, he found that he had been transformed in his bed into an enormous bug” is Franz Kafka's superbly mesmerising opening to his novella The Metamorphosis. Kafka describes, in colourful, evocative detail, how this initially bed bound and haplessly transformed creature tries to survive. Its predicament could be interpreted as psychotic: dreamlike and detached from reality. He barricades himself in his bedroom to avoid family, and his voice changes to “animal-like”—monosyllabic and unintelligible. With disordered speech, perplexed and lost in time, but paradoxically calm and initially insightless in a nightmarish yet serene universe, the “bug” struggles on. Psychosis has been associated with loss of personal identity—hence a bug—and a variety of hallucinations, visual, somatic, and auditory, can be teased out from Kafka's descriptions. More subtle changes, such as sleep reversal and changes in taste (the bug eats only rotten food), and anorexia are also in evidence.

Modern connotations of Gregor's “mental illness” include being in seclusion, stigma, and disability, and his father physically assaults the creature he perceives as dangerous. We can observe his family's social decline, burdened by shame and the expense of looking after their metamorphosed son; they eventually give up, bitter, tired, and angry. With the end approaching the bug attempts one final rapprochement with his family and then crawls out after hearing his sister playing the violin, desperate for love and affection. As a climax to this terribly poignant and heart wrenching tale, the bug, having lost much weight, loses the battle with life, and the body is discreetly and unceremoniously disposed of.

Works of fiction with aspects that are relevant to medicine, including writers' own experiences of illness, are a rich resource for doctors. A medical classic should not necessarily be a book written specifically about medicine. Aubrey Lewis, former chairman of psychiatry at the Institute of Psychiatry, is known to have advised his students to read Kafka's books, saying that the best way to study psychiatry is to observe such patterns of thoughts and behaviour. Kafka's two main novels, The Trial and The Castle, are also rich in connotations with relevance to modern psychiatry. The Trial's main character, K, is paranoid and persecuted in a complex dictatorial bureaucracy, where he is being convicted for no apparent reason. His days are ended when two strangers forcibly take him from his residence (possible passivity phenomenon in the form of made actions) and, after failing to make him commit suicide, drive a knife into his heart. In his final novel, The Castle, which ends incomplete in mid-sentence, many psychotic features are also in evidence.

Born in Prague, Franz Kafka (1883-1924) was one of the greatest German language novelists and short story writers of the 20th century. His unique body of writing—in the Prague German dialect spoken by the German Jewish minority in the Bohemian capital—much of it incomplete and published posthumously despite his wish that it be destroyed, is considered highly influential in Western literature. The adjective “Kafkaesque” has become commonly used to denote the mundane yet absurd and surreal.

It is generally agreed that Kafka had clinical depression, social anxiety, and many other stress exacerbated ailments throughout life. He is known to have said, “I have the true feeling of myself only when I am unbearably unhappy.” Aged 42, he died of tuberculosis at a sanatorium near Vienna, apparently from starvation. His famous quote, “A book should serve as an axe for the frozen sea within us,” is a legacy to modern writers and doctors alike.