“His motor neurons are being poisoned by a cocktail of toxins, the recipe unknown to his doctor and every scientist on the planet, and his entire motor neuron system is in a death spiral.”

This passage exemplifies Genova’s knack for couching medically accurate concepts in evocative, poetic language. Here, her diction characterizes ALS as a fatal poison that exceeds the understanding of trained specialists. More than a dry medical phenomenon, ALS becomes, for Richard and for readers, a vivid and destructive force.

“Using language to convey the magic of Brahms would be like using a wooden classroom ruler to measure the speed of light.”

Here, Genova uses a simile to capture Richard’s feelings about the music of German composer Johannes Brahms. As the disease progresses, the loss of his ability to create music stings Richard perhaps more than any other. The loss cuts to the core of Richard’s identity as a musician, leaving him to ponder who he is when that avenue of artistic expression is eliminated.

“Could Karina have seen the red flags through the thick haze of lust at twenty? Was there any way to predict all that would unfold? Possibly.”

Richard’s diagnosis with ALS proves to be a catalyst for him and Karina to reflect on their shared history. As they do so, each uncovers regrets as well as hopes for potential reconciliation and renewal. Here, Karina wonders whether she could have foreseen the deterioration of her marriage to Richard. Her inconclusive answer mirrors her inability in this moment to foresee the turns her life will take over the course of the novel as she cares for Richard and returns to her roots as a