Madness and Social Control in Blood on Her Tongue

The Thematic Claim: Madness as a Tool of Confinement

In Blood on Her Tongue, Johanna van Veen argues that nineteenth-century notions of madness were less about medical truth and more about policing female behavior. When a woman defied social, sexual, or domestic expectations—whether by speaking of an impossible threat, loving another woman, or simply being inconvenient—she risked being labeled insane and removed from society. The asylum was the ultimate cage, and the diagnosis was the key that locked it. Yet the novel complicates this critique by presenting characters whose actions genuinely blur the line between supernatural reality and mental illness, forcing both the reader and the protagonist Lucy to question what is truly mad.

Sarah’s Dismissed Testimony: Madness Silences Truth

From the moment Lucy arrives at Zwartwater, Sarah’s illness is framed by the men in her life as a “fever of the brain” that produces paranoid delusions. Arthur, the doctor, dismisses Sarah’s terror of the bog woman as the ravings of a sick mind, and Michael paints her as dangerously irrational. Sarah herself fears this label: she whispers to Lucy that “people have been sent to asylums for much less,” connecting her present state to her dead aunt’s fate. The novel shows that Sarah’s “madness” is actually a rational response to a real supernatural threat—the bog woman, later called Marianne, is a revenant who hungers for blood. Yet because Sarah is a woman, and because her testimony is filtered through male authority, her warnings go unheard. The letter from Dr. Rosenthaler, forwarded by Arthur, reduces her condition to le dérilité des négations (Cotard’s delusion), a clinical diagnosis that neatly explains away the existence of the bog woman. Van Veen thus reveals how the medical establishment could be weaponized to discredit women’s experiences.

Aunt Adelheid: The Asylum as Punishment for Deviance

The backstory of Aunt Adelheid provides the clearest example of madness as social control. Adelheid was brilliant, unmarried, argumentative, and a “raging sapphist”—a woman who refused to fit the mold. When her lover Vera left, Adelheid’s grief manifested as crying, fighting, and “hysterical” fits. Her brother-in-law responded by locking her in her room and summoning a doctor who “diagnosed her with hysteria” and attempted a treatment that amounted to sexual assault. When that failed, she was committed to a private asylum, where she died within a year. Van Veen makes explicit that Adelheid’s same-sex desire, her intellectual pursuits, and her confrontational personality were all reasons she could have been committed, but the final trigger was her emotional unmanageability after losing Vera. The asylum becomes not a place of healing but a prison for women who cannot be controlled by their families. Not-Sarah later reflects that the family could have had Adelheid locked away for half a dozen things, underscoring how flexible the definition of madness was when applied to inconvenient women.

The Threat of Commitment as a Leverage Tool

Throughout the novel, the threat of the asylum hangs over all the women. Lucy is drugged and told she was “hysterical” and that Michael thought they might have to commit her alongside Sarah. Magda, the maid, tells Lucy that Sarah may be in the madhouse already. The men—Michael, Arthur, even Dr. Rosenthaler by letter—collude to control the narrative of Sarah’s illness, painting her (and by extension Lucy) as unstable to justify their actions. Michael warns Lucy that if she continues to resist, she risks being locked up too. The threat is not abstract: Lucy knows that Aunt Adelheid died in an asylum, and Sarah is terrified of the same fate. The final plot turn—Lucy killing Michael and Arthur to prevent Not-Sarah’s commitment—shows that the only escape from patriarchal control is violence or disappearance. The women stage an elopement and vanish, choosing to live outside society rather than be subjected to its “care.”

Complexity and Contradiction: When Madness Is Real

Van Veen does not offer a simple “madness is a social construct” thesis. Sarah’s alter ego, Not-Sarah, is genuinely dangerous—she kills, drinks blood, and proposes cannibalism. The bog woman is a real revenant. The novel thus presents a paradox: some of the women accused of madness are indeed transformed into something monstrous, yet the label “mad” is still used unjustly to silence them. The Author’s Note warns that the book contains stigmatization of mental illness, and the author explains in the Conversation that “depiction is not endorsement.” By making some characters literally vampiric, Van Veen forces readers to sit with the discomfort that genuine threat and unjust social control can coexist. Lucy’s ethical dilemma—whether to mercy-kill her sister or enable her predator—mirrors this theme: the men’s drive to commit Sarah is cruel, but Not-Sarah is not safe to have around either. The only resolution is an ambiguous escape, leaving the question of madness unresolved.

Symbol Connections

The bog body symbolizes how women who are feared or found inconvenient are physically staked down, silenced (stone in mouth), and erased. The silver pen/eye-gouging connects to the silencing of women’s voices—the pen that wounds the tongue, the eye that sees truth is gouged. Blood and feeding represent the parasitic nature of the men who drain women’s lives—Michael, Arthur, the system itself. The posy ring is a symbol of false romantic promises that trap women.

Study Questions and Answers

1. How does the medical establishment collaborate with patriarchal control in the novel?
Arthur uses his authority to diagnose Sarah with “fever of the brain” and dismisses her claims about the bog woman. He consults Dr. Rosenthaler, who offers a convenient diagnosis (Cotard’s delusion) that pathologizes Sarah without investigating the corpse. The men trade letters and diagnoses, effectively creating a medical justification for commitment.

2. Why is Aunt Adelheid’s story important to understanding the theme?
Adelheid is a warning: she was committed not for real madness but for sapphism, grief, and an argumentative nature. Her fate shows that any woman who defies gender norms could be locked away. Lucy and Sarah both reference her to articulate their own fears of the asylum.

3. In what way does the novel complicate the idea that madness is purely a social construct?
Sarah/Not-Sarah genuinely becomes a vampire-like creature who kills and craves blood. The bog woman is real. This means that some women labeled insane actually are dangerous, making the diagnosis partially accurate—yet the men still use it unjustly to silence truth and exert control. The novel refuses a simple either/or.

4. What role does the threat of commitment play in Lucy’s decisions?
Lucy’s fear that Sarah will be sent to an asylum drives her to conceal Not-Sarah’s true nature, to manipulate Katje, and ultimately to murder Michael and Arthur. The threat gives the men power over the women even when not executed, as seen when Lucy is drugged and told she acted like a madwoman.

5. How does the author’s own background (as a triplet) relate to the theme?
In the Author Conversation, Van Veen explains that twins often develop a dominant-submissive dynamic. Lucy’s identity is subsumed into being a twin; when Sarah is threatened, Lucy feels her own self is threatened. This psychological vulnerability makes Lucy more willing to commit violence to preserve Sarah, showing that the social control of one woman can ripple out to another.