I'll start by saying that I thoroughly enjoyed this book. You can read the plot summary in the book description or other reviews, I'll talk here about some of the elements of the book that I found significant.
I would have thought you might have to be from the South, or to have been immersed in Southern culture at some point to really like this book, but I see some Yankee reviewers also gave it high marks, so I could be off base about that. One thing I love about Southern authors is the lyrical prose, and Patterson doesn't hold anything back in this work of story-telling. Occasionally hyperbolic, but often just very descriptive, I found myself smiling throughout at isolated passages of entertaining prose. Some readers may be put off by the profanity that peppers the dialogue, or perhaps by the fact that much of that comes from the mouths of the story's prominent older women, who gleefully insult one another and anyone else within their range, while doling out love and wisdom at the same time. I did not find it offensive at all, but saw it instead as a fairly realistic depiction of the strong women who carry the burden of coping and keeping everyone moving forward in the hard, sometimes brutal, life that can be found in the rural South.
The story itself is a bit convoluted, and it does seem as though everyone knows what's going on except the protagonist, Dean Adam "Duddy" Doogan (and thus the reader, as it's told from Duddy's POV). Obstacles are deliberately placed in his way, and clues planted years ago lead him forward. Those bits of artifice are what stop me from giving the book 5 stars instead of 4. Beyond that, though, this is a rollicking good yarn set in the context of a verdant southern river community, populated by a collection of Characters with a capitol C. Everyone here is related to everyone else, and the history of this huge and twisted, sometimes circular, family tree is as relevant to contemporary characters as the current events are.
Some elements of mythology are present here; the protagonist himself is a prodigal son; he is given a quest (to collect a dispersed set of music boxes that will lead Duddy to the remains of his father); the Fates (in the form of great-aunts and godmothers) are pulling some of the strings to simultaneously steer his course and confound him; heck, even the River Styx makes an appearance, complete with a bargeman to carry the protagonist into the underworld. In spite of this, the hero never becomes larger than life. Duddy is a fairly relate-able guy, confused and well-intentioned, just trying to do what needs to be done. He stops short of being either hapless or Heroic-with-a-capitol-H, when blundering into bad situations he just puts his head down and does what he needs to do to survive and go on. Villainy is abundant, in the family's dark history as well as in the living descendents. And though there is great darkness in the family and in the story, goodness and hope are everywhere, in small actions and great sacrifices.
I expect I'll be mentally chewing on this book for some time to come, and to my mind that's what makes a good read.