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Motifs are recurring structures, contrasts, or literary devices that can help to develop and inform the text’s major themes.

Snow

The story begins with an ominous March snowstorm in Kentucky, surrounding the cozy, firelit home of David and Norah Henry with peril, where Norah is already in premature labor with twins. This same snowstorm functions as an adversarial force to reroute Norah’s delivery at a safe hospital to a deserted clinic, abetting the monumental medical deception that Dr. David Henry perpetrates on his wife. David becomes obsessed with snow for its reassuring blanketing qualities that he imagines hide uncertainties, muffle discordances, and obscure mistakes. A young doctor, first in his class with an excellent clinical reputation, David nevertheless cannot uproot the deep insecurities from growing up poor that make him feel like an imposter among his colleagues. Snow ultimately represents the way secrets can be covered until the surface melts and reveals the truth underneath.

Bones

The protagonist David Henry discovers his calling to be an orthopedic surgeon when he sees an x-ray of his foot at a shoe store. Those hidden structures supporting the human body’s integumentary system speak to him of life’s connections, contained and stable. Bones have a durability compared to delicate organs and tissues, able to survive even cremation’s high heat. Bones have plasticity and knit themselves back together. As a surgeon, David could set bones back in place and watch them heal. David’s identity as a conscientious doctor clashes with the resulting guilt he experiences after giving his daughter away.

Rivers

The geographic features of rivers mark characters’ rites of passage throughout the book. Caroline marks her passage over the Kentucky River as she drives Norah’s stolen baby to the Home for the Feebleminded. Caroline follows the Ohio River to Pittsburgh when she leaves Kentucky to start a new life with Phoebe. The powerful energy of the Ohio River flowing through Louisville calms Norah’s agitation in her grief over the loss of Phoebe. In Pittsburgh, David contemplates suicide where two rivers, the Monongahela River from West Virginia and the Allegheny River from Pennsylvania, converge, their confluence forming the Ohio River flowing to Kentucky. The rivers represent the influences from David’s past converging in his moment of crisis.

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