Like much of Tan's work, this book deals with the relationship between an American-born Chinese woman and her immigrant mother.

Meanwhile, as Lu Ling is showing signs of dementia, Ruth struggles to juggle her mother's illness, her job, and her relationship.

Although she loves her mother, she also resents her for having criticized her harshly when she was young and forcing her to obey strict rules.

Lu Ling's story goes further back, describing Precious Auntie's childhood as the daughter of a local bonesetter.

The teenaged Precious Auntie is the only person who knows the location of a hidden cave where many ancient "dragon bones" can be found, knowledge that she retains even after being burned and coming to live with Lu Ling's family.

Lu Ling lives in the orphanage as a teacher through World War II, often going to extreme lengths to protect the students from the Japanese soldiers and other dangers.

The opera condenses the novel's plot through various devices: it omits peripheral characters and the subplot about the Christian orphanage and expands Chang the Coffin Maker into the key villain.

The other members of the premiere cast included mezzo-soprano Zheng Cao singing the dual roles of Ruth and the youthful Liu Ling, mezzo-soprano Ning Liang as Old Lu Ling, bass Hao Jiang Tian as Chang, folk/pop vocalist and suona player Wu Tong as the Taoist priest, baritone James Maddalena as Ruth's husband, Art Kamen, mezzo-soprano Catherine Cook as Art's mother Arlene Kamen and as Madame Wang in the flashback to Immortal Heart village, bass-baritone Valery Portnov as Art's father, Marty Kamen, with 14-year-old Madelaine Matej and 17-year-old Rose Frazier, respectively, playing Art's teen daughters, Dory and Fia Kamen.

The Dalian Acrobatic Troupe performed aerial and floor stunts and played numerous supernumerary roles alongside the San Francisco Opera Chorus.

An adaptation of the book debuted in Seattle, WA on June 10, 2022, when Book-It Repertory Theatre produced a world premiere.