What inspires us?

 Sometimes it’s a character that pops into our heads.  Sometimes it’s a news story about a shocking crime, or it’s an incident we hear from a friend.  I’m often asked where I get my inspiration from, and I have to admit I’m an idea slut — I’ll take ’em wherever I can get ’em.

But sometimes, books are launched by the sheer hunger to know more about a subject, by the drama of something so significant in the course of human events that you just want to bring it to the page. 

Here’s what inspired THE BONE GARDEN.  (It’s a somewhat shorter version of what’s posted on the BONE GARDEN website  page.)  It was a piece I wrote specifically for booksellers, but I thought that my readers (and bookclub participants) might be interested in getting a peek at the true horror stories behind the book:


It was an era of filthy knives and infected hospital wards, an age when doctors committed gruesome atrocities — all in the name of healing.  Although I’m a doctor myself, I was not well acquainted with this dark and tragic history of medicine.  But several years ago, while preparing for a speech about Mary Shelley’s novel Frankenstein, I discovered that the author’s mother had died of “childbed fever,” which was rampant in maternity wards during her time.  Curious about the disease, I delved deeper into the subject of childbed fever. 
            What I learned horrified me.
            In the early 1800’s, a pregnant woman admitted to a hospital’s lying-in ward knew there was a good chance she might not survive the experience.  Childbirth alone was a risky and frightening prospect, but even if a woman delivered safely, the danger was not yet over.  Soon after giving birth, the new mother might develop fever, chills, and a foul uterine discharge.  Bacterial gases would cause her abdomen to swell until her belly was taut as a drum and the pain was so excruciating that just stroking her skin elicited shrieks.  For days she might linger in agony, vomiting and shaking, her bed sheets soaked with sweat, until circulatory collapse at last led to death.  During epidemics of childbed fever, women died so quickly that coffin-makers couldn’t keep up with the corpses, and victims had to be crammed two to a casket.  In some hospitals, 25% of all new mothers died. 
            The most disturbing fact of all: The disease was unwittingly spread by doctors.
            Scientific articles written during the early 1800’s reflect the primitive state of medicine at a time when the standard treatment for almost every illness was to slit open the patient’s vein and bleed her.  Ignorant of the existence of microbes, a doctor might rush straight from the autopsy room to the lying-in ward without washing his hands.  Working his way down the row of beds, he’d examine patient after patient with his bare hands, spreading contagion – and death — through the wards.  Most doctors refused to believe that they themselves might be responsible for so many deaths.  They were gentlemen, and gentlemen did not have unclean hands! Instead they blamed the epidemics on “bad air” or weak constitutions or even “the ladies’ wounded modesty”. Only an enlightened few realized that the fault lay with the doctors.
             In America, it was a brilliant young doctor named Oliver Wendell Holmes who first realized how the contagion was spread.  In 1834, at the young age of only 34, he wrote a scientific paper urging his fellow physicians to wash their hands.  Today his recommendation seems obvious, but in Holmes’s day, it was revolutionary.  In the decade that followed, some of the most distinguished doctors attacked Holmes and his theories.  They were outraged that any such contagion could be blamed on physicians.
            I began to wonder how, with so many experts arrayed against him, Holmes had arrived at his startling conclusions.  What inspired his theories?  Had there been a particular case, a particular incident that made him suddenly realize infection was transmissible? 
            In my search for the answer, I explored a nightmarish era in medicine.  I read of medical students who secretly dug up half-rotten cadavers to study anatomy.  I read of autopsy rooms that stank so badly students desperately puffed on cigars to hide the smells.  I read accounts of battlefield amputations performed on fully conscious and screaming patients.  Consider this how-to guide for thigh amputations, published in a 1809 surgical textbook written by Dr. Samuel Cooper — a book which was still in use during the Civil War:
            “The patient is to be placed on a firm table, with his back properly supported by pillows. Assistants are to hold his hands and keep him from moving too much during the operation. The ankle of the wound limb is to be fastened, by means of a garter, to the nearest leg of the table…An assistant, firmly grasping the thigh with both hands, is to draw upward the skin and muscles while the surgeon makes a circular incision, as quickly as possible, through the integuments, down to the muscles…”

             Or consider this matter-of-fact set of instructions on how to amputate a leg below the knee:
             “The leg being properly held, the integuments should next be drawn upward by an assistant, while the surgeon, with one quick stroke of the knife, must divide the skin completely round the limb. Some recommend the operator to stand on the inside of the leg, in order to be able to saw both bones at once.”

             In any such surgery performed on a conscious patient, speed was of the essence, and a skilled surgeon could complete a simple amputation in less than ten minutes.  If the fully awake and shrieking patient survived this horrifying ordeal, there were other dangers ahead, including gangrene and lockjaw, which Dr. Cooper so dispassionately describes:
             “A stiffness is first experienced about the back of the neck.  The muscles of the lower jaw next become hard… At length, the patient cannot open his mouth at all.  All the muscles of the neck, back, and indeed of the whole body, become successively affected with the most rigid spasm.  The limbs are stiff and immovable, and the muscles of respiration, being prevented from performing their office, the patient dies.”

             To be a doctor in Holmes’s time was to see death and pestilence at every turn.  This is the era in which THE BONE GARDEN is set, a grim world where a twisted killer is at large, butchering the very people who are trained to heal.  It’s a world where the horrors committed by the killer known as the West End Reaper are matched by the gruesome horrors of the operating room.
            While THE BONE GARDEN is a crime thriller, it’s also a journey into a frightening time when doctors killed as many patients as they cured, and when brilliant men like Oliver Wendell Holmes were just beginning to understand contagion.  I wanted to give my readers an inspiring look at the first glimmerings of microbial theory.  When you read THE BONE GARDEN, I hope you’re more than merely entertained; I hope you’ll also be enlightened by this glimpse at one of the brilliant men who changed the face of modern medicine.

28 replies
  1. dustinhood
    dustinhood says:

    Now I am looking even more forward to reading THE BONE GARDEN. Since we are talking about this era, I remember something that I will never forget. It is also mentioned in James Patterson’s novel, THE 5TH HORSEMAN…burking is the term I’ve always heard it as. IN the 1800s, to study anatomy some people dug up freshly buried bodies, like mention in the blog. While Burk* (I don’t know his first name), thought of a way to get fresher corpses. He would kill them by suffocating them. I don’t mean hold a bag over their head. He would get the victim on the its back and immobilize it from moving then sit on the victim’s upper back until death arrived. Sitting on the back disabled the chest to expand and if the chest can’t expand,you can’t breathe and you suffocate. In James Patterson’s book, they were unable to find the killer because of the lack of clues.

    I thought that it was kind of interesting. That era is very interesting to me, it gets me thinking. Tess, I’m looking forward to reading THE BONE GARDEN, I’m counting down the days until its release.

    Dustin Hood, 15

  2. Tess
    Tess says:

    I actually have a character named “Jack Burke”, a resurrectionist in THE BONE GARDEN who kills someone in just that way. I thought I’d have a little fun and borrow his name from the historical “Burk”.

  3. joe bernstein
    joe bernstein says:

    i recall the first time i saw my grandfather walking around in shorts and he had a nasty purple lump on his leg-i asked him what it was and he said ‘you don’t want to know”,but i did so he told me when he was six and his father was in the russian army they lived in an outlying garrison town with primitive conditions and he was bitten by a rabid dog-so they took him right to a blacksmith’s shop and heated an iron bar red hot and put it in the wound to cauterize it-no painkillers were available and he said he was in severe pain for a week afterward and it was an experience he’d never forget-there was a vaccine available in those days(1890’s) but not where he lived out in the middle of nowhere-he died at 93 so i guess the treatment worked out-it’s weird nowadays that after many decades of antiobtics being so effective there are resistant infections proliferating,and new diseases like SARS and AIDS-maybe we got too cocky about popping a pill for any ailment

  4. Jude Hardin
    Jude Hardin says:


    I’m an RN, so I witness some of the horrors in a modern hospital, with state-of-the-art equipment and medications. People still suffer greatly sometimes, and it’s still sometimes the medical professionals at fault.

    As a physician, I’m sure you know what I’m talking about.

    Even with all we’ve learned, with all the advances in medical science, we’re still only human beings taking care of human beings. Naturally, mistakes occur. The modern profession is full of its own challenges, so it’s hard to even imagine what things were like during Holmes’s time, before the discovery of antimicrobial medications, effective and relatively safe analgesics, etc.

    And here’s the kicker: there are still signs posted in the hospital urging doctors and nurses to wash their hands. D’oh!

    Can’t wait for The Bone Garden. As a medical professional, especially, I’m expecting it to be both entertaining and enlightening.

    Kudos to you for attacking a difficult subject and an often forgotten era in the evolution of medical science.

  5. Amy MacKinnon
    Amy MacKinnon says:

    Tess, you’re probably aware of the great Viennese physician Ignaz Semmelweis who also noticed the correlation between handwashing and puerperal fever. Unfortuantely for Dr. Semmelweis and his patients, he was eventually run out by his superiors for being hyper-vigilant about cleanliness. Dr. Atul Gawande also addresses the issue of handwashing in his 2007 book, Better.

    I love knowing the inspiration for a book and yours is fascinating. It will make reading The Bone Garden so much the better.

  6. JanetK
    JanetK says:

    THE BONE GARDEN sounds like it’s going to be my favorite kind of book — interesting *and* entertaining. Looking forward to getting my copy 🙂

    My grandmother (born in the late 1800s) had an odd scar on her neck. When my mother told me it was the result of a childhood goiter, I had to look up ‘goiter.’ Then 13, I had no clue about such things.

  7. Tess
    Tess says:

    after being hounded out of his profession, poor Dr. Semmelweis ended up dying in a mental institution of sepsis, after cutting his finger. (I mention him in a chapter of the book.) It’s astonishing how many close-minded doctors through the centuries have held back the progress of medicine.

  8. Julie K. Trevelyan
    Julie K. Trevelyan says:

    Good grief. Haven’t read The Bone Garden yet, and now am simultaneously looking forward to it, yet also a bit nervous about all the gory details I’m sure are in it! Should I perhaps not be enjoying food as I read it? 🙂

    And my personal view of any medical profession is that doctors are human, make mistakes, cannot possibly be aware of *all* the latest research, and it behooves me to take care of my own health, by asking intelligent questions that hopefully do not offend. (I must also add that I prefer naturopaths, although I love Western emergency medicine, such as the antibiotics that saved my life when I had pneumonia several years ago.)

    It does make me curious too: a century from now, will our descendents be laughing at us in horrified disbelief at some of our current medical practices that we think are so safe and turn out to be terribly wrong? (Hey, along with not knowing about hand-washing, people once thought the world was flat too. There’s always room for new ideas.)

  9. clare
    clare says:

    I love books where I pick up new facts/ideas. Reading about certain things in a fictional context gives them a texture and perspective, when done well it can bring them alive. It’s nice to put down a book and aside from the shear escapism feel you’ve gained something; knowledge or a different understanding or perspective.

    I’d not think to pick up a factual book on medicine in the 1800 yet just reading this blog and the comments is fascinating. The glimpse into how any common knowledge is discovered. Something as simple as washing your hands and the full consequences and history.

    I do wonder how future generations will look back on current day practices.
    The thought that ECT and Trepanning are still used today despite our relative advancement. I still cringe at the thought of self-trepanation, personally I’m very grateful for off-the-shelf analgesics!

  10. struggler
    struggler says:

    Tess, having read your blog today I can’t help but think of a rapidly increasing cause of deaths in UK hospitals known as MRSA. Meticillin-resistant Staphylococcus aureus (MRSA) is a variety of Staphylococcus aureus that is resistant to meticillin, and some of the other antibiotics that are usually used to treat S. aureus. Those who die with MRSA are usually patients who were already very ill, and it is their existing illness, rather than MRSA, which is often designated as the underlying cause of death.

    The number of death certificates mentioning MRSA infection increased dramatically from 51 in 1993 to 1,629 in 2005 (a 4000% increase) in England and Wales, i.e. not including Scotland or Northern Ireland.

    Some of the recent increase in mentions of MRSA on death certificates may be due to improved levels of reporting, possibly brought about by the continued high public profile of the disease.

    So despite the extraordinary advances in medicine over the past 200 years, we still face problems that bear more than a passing resemblance to those that you refer to above (when a doctor might rush straight from the autopsy room to the lying-in ward without washing his hands). MRSA is, I understand, spread in a similar way and all hospital staff are under intense pressure to wash their hands thoroughly many times a day especially when moving from one area of the hospital to another.

  11. Kyle K.
    Kyle K. says:

    Hey Tess!

    Do you every get any ideas for stories completely out of left field? (I don’t need specifics!) Like, ever had the idea for a Fantasy/Sci-Fi novel? Or a straight up literary drama? Or maybe even a TV show or movie? If so, what do you do with those ideas?

    Just curious!

  12. Craig
    Craig says:

    Johnny Gruelle’s daughter, Marcella, died from an infection caused by a dirty (re-used) hypodermic needle at the age of 13. Johnny Gruelle was the creator of the Raggedy Ann and Andy stories and some of them, especially the short stories about Marcella are absolute heartbreakers.

  13. mcrown
    mcrown says:

    I am looking forward to buying this book. I’ve enjoyed other books from this genre (e.g. The Alienist & The Dante Club). I also believe it is a wise business move. Your numbers will no doubt grow with the release of this book.
    P.S. Thanks for the writing this blog…very insightful.

  14. Tatiana
    Tatiana says:

    Thanks. Thanks a lot. Now I might have to take this book off of my Christmas wish list and buy when it comes out. No doubt I’ll end up reading it instead getting my projects and term papers done.

    Darn you. 😛

  15. NewMexicanAnn
    NewMexicanAnn says:

    Tess: Unfortunately, there are close-minded doctors today. I work for a clinical neuropsychologist and was reminded just this week that some PCP’s don’t want to have a “mere” neuropsychologist call them and give their impressions, even if it’s for a patient’s benefit.

    Also, from what little A&P I’ve had, that “childbirth fever” you mentioned sounds like puerperal sepsis to me. And it can happen after abortions as well as childbirth, which is why abortions done by quacks instead of real doctors in sterile conditions are so dangerous. But I bet you know all that. 🙂

    Can’t wait to read your book!


    P.S. Wouldn’t shock also be a risk of amputation?

  16. NewMexicanAnn
    NewMexicanAnn says:


    I’ve heard of MRSA. It’s a nosocomial infection, isn’t it? My PCP once told me that if you’re very sick, the worst place to be is in the hospital, and you know what? He’s right! 🙂 But I suppose that’s also why, if you’re hospitalized, they ask you if you’ve had a pneumonia shot recently.

  17. GerritsenFever10
    GerritsenFever10 says:

    Seeing as how the most major advancements in modern medicine have occurred within the past century I think that early doctors were doing the best that they knew how given their knowledge of medicine was very brand new. Afterall, if we didn’t have their early mistakes to learn upon what would we have today but the same crude measures of operation. Liquor was very commonly used (in copious amounts) during the civil war “field surgeries” because doctors knew that alcohol had numbing effects and would therefor at least lessen the severity of the pain inflicted by crude surgical procedures. As for sanitation it wasn’t really even considered until Florence Nightingale came about and soaked the “surgical instruments” in water before each amputation was performed and would clean the patient’s wound before amputation. This pioneer nurse realized the deadly consequences of using dirty, bloody saws and the like on one patient after the other. Very interesting era indeed Dr. G, really can’t wait for release day now!

  18. Paul
    Paul says:

    Hi Tess,

    I am reading Madame Bovary at the moment, a book that becomes more beautiful with the turn of every page. In that they try to treat poor Hippolyte’s clubfoot by simply slicing through his achilles tendon. He quickly develops gangrene and has to have one of those nasty amputations you describe.

    What’s so admirable about Holmes is that he was so far ahead of his time.

    I have just read the first chapter of Bone Garden at the back of the Mephisto club paperback and really enjoyed it. Please feel free to email me the rest of the chapters asap.


  19. Tess
    Tess says:

    NewMexicoAnn, yes, childbed fever is another name for puerperal sepsis — which can occur whenever there’s unsterile instrumentation around the time of delivery.

    And in that era, some doctors believed that during amputation it was better to have the patient awake and in agony because they were thought to recover faster afterwards!

  20. Tatiana
    Tatiana says:

    Well, if by recover you mean get as far away from the doctor as soon as possible, they may have been right.

  21. joe bernstein
    joe bernstein says:

    i noticed an article in today’s paper that childbirth deaths are rising in the usa-they aren’t sure if it’s due to more obese women getting pregnant or some other medical factors or better reporting-recently here in providence they opened the wrong side of a patient’s skull to operate for bleeding in the brain,so they had to re-do it-now the patient has died a few weeks later-they haven’t determined if the botched surgery was a factor,but it couldn’t have helped any

  22. NewMexicanAnn
    NewMexicanAnn says:

    joe: I saw the same article today. They were blaming it on more obese women getting pregnant and they were also blaming it on CT sections. Good article.

  23. Gabriele
    Gabriele says:

    Oh, that evokes memories of the time when I was about 14 and read every book about the history of medicine from Aegypt to WW2 I could find. Fascinating stuff.

    I still read such books, and in my trilogy-in-progress, scenes with a medical context keep creeping in – no wonder with all those battles my Romans get involved in. 🙂

    Definitely looking forward to Bone Garden.

  24. Kristin G
    Kristin G says:

    I love the ick-factor, Tess! REAL horror such as you describe is infinitely fascinating to me. To know how people used to deal with all types of medical situations before ‘modern’ medicine is a very interesting topic. Especially after having had two children myself, I feel for these women of the past and how much courage it took just to bring a child into the world.

    I am so excited about your book. This is right up my alley. Thanks for sharing your research with us. I was riveted all the way through and can’t wait to read more about Oliver Wendell Holmes.

  25. struggler
    struggler says:

    It makes me wonder though at what people will be saying about 21st century medical standards 200 years from now. Will they be talking about “those poor people back in 2007 who died from an illness that was called cancer”? Smallpox has been pretty much wiped out, and I believe instances of TB are way way down on the 19th century. Today we talk of heart disease, cancer and strokes being the ‘big three’, maybe they will have all but disappeared by the year 2207….might sound crazy but imagine the reaction of people in 1807 if they were told about (for example) heart transplants in the future, or the fitting of artificial lower legs enabling the user not just to walk unaided, but to run as well.

  26. joe bernstein
    joe bernstein says:

    struggler-don’t get too confident about tb-it may not be as widespread as in the past but there are new resistant strains and in the usa many illegal aliens carry tb-i recall that almost all the restaurant workers we picked up as far back as the 70’s when i was an INS agent assigned to chicago were taking kanamycin,which is used to treat tb-combine that with the filthy conditions they lived in and it could turn you right off eating in restaurants-after one of our chinese speaking agents died as the result of a scratch he got on a smuggling ship(some aggresive bacteria) the agency instituted annual pathogen exposure training and finally tested us for tb and gave hepatitis shots-of course a young man in his 30’s had to die to get them off their collective ass

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