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The eNotes article on Themes and Characters has a very good summary of the novel. I've pasted a link to it below.
Set in England during the mid 1700s, Coram Boy is the disturbing story of a man and his son who do an evil thing. Otis Gardiner and his son, Meshak, are peddlers; that is, they travel from town to town selling pots, pans, and other household goods. When the Coram Hospital, an orphanage in London, opens, Otis finds another source of income. For a fee, he claims to take the children that mothers can no longer care for or that were born illegitimately to the hospital. However, he sells the older children into slavery and makes his son bury the babies alive.
Although his father thinks he is simpleminded and has no remorse for what he has done, Meshak can't sleep for guilt. When Alexander Ashbrook and Melissa Milcote fall in love and have a son, Melissa's mother tells them that the baby died, but she secretly gives him to Otis. This time, however, Meshak decides not to kill the child. He believes that Melissa is the angel he keeps seeing in his dreams, so he decides to protect her child. The baby is named Aaron, and Meshak watches over him and Toby, a young African boy whom Otis had planned to sell.
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