The Night Surgeon's Quarantine

• Chapter 1 The Bolt Drawn Tight
• Chapter 2 A Surfeit of Yellow Bile
• Chapter 3 The Beak and the Bribe
• Chapter 4 Requisitioning the Leech-Pail
• Chapter 5 Four Humors, Zero Wits
• Chapter 6 An Imperial Pint of Purest Blood
• Chapter 7 Form Forty-Two: Clearance to Sneeze
• Chapter 8 Mercury for Breakfast
• Chapter 9 The Astrological Inquest
• Chapter 10 A Disagreement on Fontanelles
• Chapter 11 The Ward Warden’s Stamp
• Chapter 12 Smelling of Rosemary and Despair
• Chapter 13 The Sovereign Clyster
• Chapter 14 The Committee of Bedpan Scrutiny
• Chapter 15 A Poultice of Questionable Purity
• Chapter 16 Phlegm in the Ledger
• Chapter 17 The Doctor’s Latin Excuses
• Chapter 18 Protocol for the Moribund
• Chapter 19 Boiling the Treacle
• Chapter 20 An Unauthorized Pulse
• Chapter 21 To Purge a Magistrate
• Chapter 22 The Black Bile Blackout
• Chapter 23 The Apprentice's Counter-Prescription
• Chapter 24 Incinerating the Miasma
• Chapter 25 A Miracle of Bureaucratic Recovery
• Chapter 26 The Dawn Parole

The heavy iron bolt fell into its socket on the exterior of the oaken door with a sound remarkably like the dropping of an executioner’s axe, though considerably less merciful, for an axe at least ended the administrative paperwork.

Outside in the chill autumn drizzle of Southwark, a pair of parish watchmen were already hammering iron staples into the frame. Master Christopher Finch, Licentiate of the Company of Barber-Surgeons by grace of his late uncle’s unpaid loans, did not look up from the scrubbed pine table where he was carefully arranging his brass spatulas in order of descending rustiness. He had heard that sound forty-two times since the coronation festivities of King James had brought three hundred thousand potential corpses into London to breathe upon one another. Forty-two quarantine seals, each one affixed with the broad, indifferent thumb of the local beadle.

"Listen to that timbre, Ned," Doctor Theophilus Plume murmured, tilting his bewigged head toward the shuddering timber. He lifted a single, manicured finger to freeze the air, as if catching a stray moth of truth. "Oak from the Weald, seasoned seven winters. A resonant timber. A defensive barrier against the pestilential vapor of the lower orders. You hear an enclosure, boy; I hear the civic state asserting its harmonious boundaries against the corruptive effluvia of the ditch."

"I hear three pence worth of wrought nail holding us in with forty-four dying weavers, Master Plume," Ned said. He wiped an oily rag across the curved belly of a pewter fleam, inspecting the edge against the meager light of a tallow dip. The dip was three parts mutton fat and smelled persistently of burnt chops. "And I hear the beadle coughing through the keyhole. It was not a clear cough, either. It had the thick, buttery note of a man whose lung-moss is turning green."

"A bronchial rheum merely," Plume said with an airy sweep of his sleeve, which was trimmed with rabbit fur that had lost its youth during the later years of Queen Elizabeth’s reign. "A superfluity of winter phlegm, occasioned by his standing in the puddles outside the Boar’s Tusk after eating salted herrings. The external beadle is an animal of watery disposition. His liver lacks the noble furnace of our own."

Plume turned his attention to his mirror—a modest square of silvered glass framed in cracked ebony—and adjusted the ribbons of his starched ruff. The ruff was yellowed at the perimeter where vinegar fumes had licked it during previous disinfections, giving him the appearance of an austere, disgruntled sunflower.

"Let the watch nail what they will," Plume declared, reaching for his pomander. It was a pierced gold-plated walnut shell stuffed with dried rue, calamus, and the scrapings of an old nutmeg. He held it beneath his long, thin nose, inhaling with the rhythmic gravity of a bellows. "We are within the citadel of Art. We possess the Galenic charter. When the sun rises over Bermondsey, we shall present the Alderman’s deputy with a clean ledger, signed in triplicate, demonstrating that within these walls the humors were brought into perfect equilibrium through the judicious application of rational physics."

"We shall present him with twelve bushels of soiled straw and seven men who cannot remember their own Christian names," Ned remarked. He did not say this out of malice; it was merely an accounting. Ned had been apprenticed to Plume for three years, during which time he had learned that Latin was twenty times more durable than flesh, and that an apothecary’s bill was the only document that survived an outbreak entirely undamaged.

The infirmary of Saint Jude-in-the-Muck had originally been a wool warehouse, a fact commemorated by the smell of greasy lanolin that rose from the floorboards whenever the humidity reached a certain pitch. It was long, narrow, and entirely devoid of windows save for three high, narrow slits near the rafters, which had been greased with sheep’s fat to keep out the draft and consequently admitted only a yellow, butter-colored murk that revealed nothing except the thickness of the dust.

Down the central aisle, twenty-two pallet beds were arranged on either side. Most held two tenants; some held three, provided they were of similar stature or sufficiently weakened by the spotted ague to offer no physical objection to being wedged shoulder-to-shoulder like herrings in a barrel. A low, continuous drone filled the room, compounded of groans, prayers in half-forgotten Latin, the wet rattle of chest-fluid, and the clicking of several hundred rosary beads that were being worked with the furious speed of men who suspected their credit in heaven was running out faster than the candle tallow.

At the far end of the room, near the cold hearth, an elderly man named Gudge sat upon an overturned tub, stirring a pot of cold barley water with a broken bed-slat. He was the ward’s designated nurse, appointed by the Vestry because his extreme deafness prevented him from being distracted by the screaming, and because he had already survived three different pestilences through what he claimed was an exclusive diet of pickled cabbage and Dutch gin.

"Ned," Plume said, laying down his mirror with a sharp clatter that startled a large brown rat from its residence beneath the washstand. "The inventory. We must establish the baseline. A physician without his inventory is but a sailor without his astrolabe, drifting upon a sea of disordered fluids."

Ned reached into his pocket—an capacious pouch of boiled leather that contained three dirty lancets, a piece of chalk, a dried pig’s bladder for collecting humors, and half a pork pasty he had bought near London Bridge before the gates were shut—and drew out a curled sheaf of vellum. It was headed, in an exquisite clerkly hand that Plume had spent two hours perfecting while the first three patients were vomiting blood into the wood-shavings: A True and Particular Reckoning of the Corpora and their Derangements within the Parish Lazaret of Saint Jude-in-the-Muck, 12th October, Anno Domini 1603.

"Read the preamble," Plume commanded, puffing his chest so that the rabbit fur bristled against his doublet. "Let us remind the room of the dignity of the endeavor."

"The room is asleep, Master, or wishes it were," Ned said.

"The preamble, Edward. The forms are the only things that distinguish our proceedings from the butcheries of the German empirics."

Ned sighed, a dry, clicking breath that smelled faintly of onions. "Whereas by order of the Lord Mayor, the Court of Aldermen, and the Worshipful Company of the Art and Mystery of Barber-Surgeons, it is decreed that no man, woman, nor suckling child shall depart this precinct until forty days have elapsed from the last appearance of the black carbuncle, the parotid swelling, or the purple vibices commonly called God’s Tokens..."

"A noble sentence," Plume murmured, his eyes half-closed. "Balanced. Cicero himself would not have disdained the cadence of 'purple vibices.'"

"...and whereas the care and disposition of the aforesaid bodies is committed to Doctor Theophilus Plume, Master of Arts of the University of Cambridge, and Edward Crisp, his bound servant, to be treated according to the ancient authorities—to wit, Hippocrates, Claudius Galenus, and the Arabian Avicenna—without recourse to unlicenced nostrums, chemical salts, or the superstitious practices of women who dwell in alleys."

"Excellently recited. Note that down: all things regular and according to the custom of the faculty. Now, what is our opening strength?"

"We began the afternoon with forty-eight," Ned said, consulting the marginalia. "We lost the cooper’s widow at four o’clock, but she was not on the ledger because her nephew had not yet paid the fourpence registration fee for her bedding. Then we took in the two watermen from the Queenhithe stairs who were found lying in a skiff with their oars crossed. That brought us to forty-nine. But Master Gudge dropped the small chimney-iron on the smith from Horseshoe Alley while trying to kill a spider, which leaves us at forty-eight again, though the smith is still technically breathing if you count the froth."

"The smith must be accounted for under the heading of Accidental Perturbations," Plume said, taking the pen from behind his ear. "We cannot allow mechanical contusions to disorder the epidemic tables. It would give the College of Physicians a false impression of the local air. The College is very particular about the air of Southwark; they believe it to be predominantly dry and adust, owing to the proximity of the tanners’ pits."

"The tanners’ pits are three feet deep in bilge, Master," Ned noted. "The air smells like an old boot that has been used to drown a cat."

"The senses of the vulgar are easily misled by gross vapors, boy. To the philosophical mind, the tan-bark produces an astringent exhalation which actually represses the putrefactive motion of the bile. If the smith dies, he dies of an excess of bone-splinters in the cerebrum, which is an orthopaedic matter and belongs to the lower guild. I will not have my plague statistics corrupted by a clumsy nurse and a chimney-hook. Cross him out with a single thin stroke—do not blot—and write Referred to the Common Pity in the margin."

Ned took the piece of chalk and made a small mark upon the floorboards near his feet, alongside forty-seven others that were arranged in clusters of five, like the palings of a fence. "He’s crossed. That leaves forty-seven full-titled patients, two dogs which Master Gudge insists are necessary for clearing the trenchers, and the dead tinker behind the wood-pile."

"The tinker? Why is the tinker still behind the wood-pile? The Searchers of the Dead were notified at noon."

"The Searchers are two ancient women from the almshouse who cannot climb the stairs when the beer is high," Ned explained without looking up. "They came as far as the tavern at the corner, drank two pots of buttered ale at the parish charge to fortify their spirits against the contagion, decided the lane was full of devils, and went back to their beds. If the tinker wants to be buried before Friday, he will have to move himself to the window so they can poke him with their white wands from the street."

Doctor Plume adjusted his ruff once more. It was a nervous habit he had acquired during his brief and financially disastrous tenure as physician to a nobleman who had died of a quinsy while Plume was still explaining the third book of the Method of Medicine to the grieving heir.

"The tinker must wait his turn," the doctor said firmly. "Order is the first law of health. First the inspection of the humors; then the evacuations; then the diet; and finally, if the vital spirits prove obstinate, the registration of the certificate. Bring me the basin, Edward. We shall begin with the tallow-chandler in Bed Number Four. I observed him earlier through my spyglass. His complexion was distinctly pomegranate. A man cannot carry a pomegranate face into the night without a significant rebellion of the sanguinary vessel."

"He was only red because the roof leaks over his pillow," Ned said. "The rain comes through the thatch where the pigeons nested, and it has been dripping on his forehead since the third bell. He was trying to catch it in his mouth."

"An unnatural thirst," Plume retorted, rising from his chair with an immense rustle of starched linen and stiffened broadcloth. "A certain sign of interior ebullition. The blood is boiling in the vena cava like wort in a copper. If we do not open a vein before the third hour of the night, the grosser parts will precipitate into the joints and we shall have an internal gout on our hands, which, as you well know, requires three separate syrups of wild endive that the Company has neglected to send us."

He reached into his leather instrument-case, which sat upon the table like an open jewel-box of small, glittering implements of torment. There were fleams with horn handles, lancets shaped like little broadswords, three varieties of tongue-scrapers made of whalebone, and a long silver probe which Plume had once used to extract a bead from the nostril of an alderman’s daughter and had never ceased mentioning since.

Ned did not move immediately. He remained leaning against the pine table, watching the small circle of tallow-light flicker against the damp wall. "Master," he said quietly, "did you look at the street before they dropped that iron bar?"

"I did not," Plume replied, selecting a medium-sized lancet with an edge like a sickle. "A physician does not gaze backward into the world of health; he looks forward into the field of his labors. The street is the concern of the parish constables and the scavengers."

"There was no one in it," Ned said. "Not a horse. Not a dray. Even the water-carriers had left their barrels by the pump. The only thing moving was three pigs from the butcher’s yard that were eating a basket of spoiled cabbages someone had thrown out of an upper window. And on the door of the church across the way, the parson had nailed a piece of paper saying he had retired to his sister’s house in Epping to seek the Lord’s will concerning the mortality."

"A very proper retreat," Plume said, testing the lancet on his thumbnail. "The clergy are of a delicate, spiritual complexion; their animal heat is easily dispersed by the gross exhalations of the unwashed. A parson in a plague-ward is like a canary in a malt-kiln—he sings once and turns over. We, Edward, are made of sterner earth. We have the three pillars: Phlebotomy, Purgation, and the Royal Charter. Bring the pewter bowl."

Ned took up the bowl. It was heavy, notched around the rim to receive a man’s forearm, and darkened inside by the stains of twenty years of therapeutic drainage which no amount of river-sand could scour away. He followed his master down the narrow lane between the pallets.

The straw was damp beneath their shoes. With every step, a faint puff of sour air arose—the smell of wet wool, human tallow, and that particular sweet, heavy reek that belongs only to places where many people are waiting together to see who will be carried out first.

Bed Number Four was occupied by Master Clout, the tallow-chandler. He was a small, round-shouldered man whose normal occupation had left him with a permanent glaze of mutton-grease about his knuckles and eyebrows. At present, however, he looked less like grease and more like dried leather. His mouth was open, his tongue was white and dry as a salted cod, and he was staring with intense concentration at a large knot in the rafters immediately above him.

"Master Clout," Plume began, adopting his bedside manner—a combination of academic condescension and the loud, slow cadence one might use with an exceptionally dull child or a foreigner from Devonshire. "You find yourself in the hands of the faculty. The night is cool; the air is thick; the planet Mars is currently ascending through the House of the Crab, which, as you doubtless are aware, excites the choler and predisposes the smaller veins to an unseemly fullness. We are going to relieve the pressure upon your liver."

The chandler’s eyes rolled slowly down from the rafter-knot until they settled upon the silver-mounted lancet in Plume’s hand. He made a sound like dry paper being crumpled.

"Water," Clout whispered.

"A common error," Plume observed to Ned, gesturing toward the patient’s throat with the blunt end of his instrument. "Notice the dryness of the tongue, the crust upon the lips. The uninstructed mind cries for water, which would merely add fuel to the internal furnace, creating an unwholesome steam that would inevitably mount to the brain-pan and induce a phrensy. What he requires is not liquid, but the subtraction of that hot, turbid humor which is currently suffocating his innate heat."

"He hasn't had a drink since noon yesterday, Master," Ned muttered. "Master Gudge drank the small beer that was brought for this side of the ward, and the pump-handle is chained because the vestry thinks the water has been poisoned by the Frenchmen who live by the docks."

"The Frenchmen are quite capable of it," Plume said without looking around. "Their humors are notoriously volatile, owing to their excessive consumption of oil and vinegar. But that is an administrative question for the Sessions. Hold his arm, Edward. Keep the thumb turned outward so that the cephalic vein presents itself clearly. The cephalic is the highway of the head; by tapping it here, at the bend of the elbow, we shall draw off the noxious vapors before they can establish a siege within the meninges."

Ned set the pewter bowl upon the mattress and took Clout’s wrist. It was hot and dry, like an old brick that had been sitting in the sun. The pulse beneath his thumb was not the noble, rhythmic stroke described in Plume’s leather-bound editions of Galen; it was a tiny, frantic flutter, like a sparrow trapped inside a wicker cage.

"Master," Ned said, his fingers tightening on the dry wrist, "he has no pulse to spare. It's skipping like an eel in a bucket. If you take eight ounces out of him now, he won't last until the Searchers finish their ale."

Doctor Plume drew himself up to his full height, which was not inconsiderable, though his shoulders had a scholarly curvature that made him appear perpetually poised to dive into a pond.

"Edward," he said, and his voice dropped to that cold, formal register he used whenever a patient’s relatives asked about the cost of the third clyster. "Are you a Licentiate of the Company?"

"No, Master."

"Have you disputed in the schools upon the distinction between the spiritus vitalis and the spiritus naturalis?"

"No, Master."

"Have you read the commentary of Jacopo da Forlì upon the Tegni of Galen?"

"You know I haven't, Master. You keep it locked in the walnut chest because the covers are stamped with real gold leaf."

"Then do not instruct your betters in the mechanics of the vascular system. The pulse is erratic because it is oppressed. It is like a bell muffled with rags; remove the rags, and the metal rings clear. We must unload the carriage if we expect the horses to gallop."

Plume positioned the point of the lancet against the faint blue line that traversed the crook of the chandler’s arm. Master Clout did not pull away; he seemed to have reached that state of administrative indifference common to long-term inhabitants of the parish wards, where whatever was done to him was simply another tax to be endured before he could be left alone in the dark.

"Steady the dish," Plume commanded.

The steel went in with a small, tough pop, like the skin of a roasted plum.

For a second, nothing happened. The chandler blinked once at the ceiling. Then a thin, dark ribbon of fluid emerged from the puncture. It was not the bright, frothy crimson that Plume’s textbooks spoke of with such poetic enthusiasm; it was the color of stewed damsons, thick and slow, and it crawled down the gray skin of the arm rather than spurting into the center of the pewter basin.

"Behold," Plume said, pointing with a blood-tipped finger. "Look at the density. The adustion. The gross, earthy particles. Had we left that in the man’s system another hour, it would have turned into a malignant carbuncle the size of a turnip. See how it coats the side of the vessel? Phlegm mixed with burnt choler. A textbook evacuation."

"It's stopped," Ned said.

The trickle had indeed ceased after barely two tablespoons had collected in the bottom of the dish. The cut remained open, a little red mouth that seemed to have nothing more to say.

Plume frowned. He took the chandler’s arm and squeezed it from the wrist upward, as if he were trying to milk the last drop of lard from a bladder. "A temporary obstruction. The vital spirits are retreating inward to protect the liver. We must stimulate the periphery. Master Gudge! Where is that old knave?"

From the dark corner by the cold hearth, Gudge did not move. He was currently occupied in cutting his toenails with a small bone-handled knife, his spectacles balanced upon the tip of his red nose by means of a greasy string looped around his ears.

"Gudge!" Plume shouted, his voice cracking slightly on the high register. "Bring the warm bricks! The circulation is sluggish!"

"He won't hear you, Master," Ned said, releasing Clout’s arm. The chandler’s hand fell back onto the straw with a dull, heavy thump, like a piece of salted beef. "Not unless you make a noise like sixpence falling into a pewter mug."

Plume stepped back from the bed, his lancet still held between his fingers like a pen. He looked at the chandler’s face. Master Clout’s eyes had ceased their study of the rafter-knot; they were now fixed upon the greasy linen ruff of the Doctor with a wide, glassy stare that seemed entirely devoid of civic respect.

"His respiration is... suspended," Plume remarked after a long pause. He reached out with the tip of his shoe and tapped the leg of the pallet. The frame did not move.

"He's dead, Master," Ned said. He took the chalk from his pocket, walked to the pine table, and rubbed out one of the white marks on the floorboards with the heel of his shoe. "Forty-six. And we haven't even lighted the second candle yet."

"Nonsense," Plume said, though he took two steps backward toward the table, his fingers instinctively reaching for the pomander at his neck. "A syncope merely. A temporary deficiency of the aerial pneuma. It frequently attends the evacuation of gross humors. Cover him with the blanket and leave the lancet-cut open; if the redundant blood finds an exit, the animal soul will return when the room cools."

"The room is already cold enough to hang a pig in," Ned said. He pulled the coarse gray coverlet over Clout’s nose, noticing as he did so that someone had already stolen the dead man’s pewter shoe-buckles while they were arguing about his liver. "And if his animal soul comes back, it will find its shoes gone. That'll make it sour."

Doctor Plume returned to the table, sat down, and took up the goose quill. His hand was slightly stiff from the chill, but he dipped the nib into the iron-gall ink with great deliberation, holding his little finger extended in the manner approved by the writing-masters of Cambridge.

"Item," he wrote, the pen scratching loudly across the vellum. "Master Clout, chandler. Visited by the grace of God and the faculty at the eighth hour. Found to be laboring under a violent plethoric distemper, with great adustion of the fluids. Relieved by phlebotomy to the extent of three ounces..."

"Two spoons, Master," Ned corrected, leaning over his shoulder.

"...relieved to the extent of six ounces," Plume continued without pausing, his script growing larger and more decorative as the lie expanded, "whereupon the internal tumult was assuaged and the patient entered into a profound and restorative rest, according to the principles of Art."

He blew upon the ink to dry it, then looked up at Ned through his small, round spectacles, which were spotted with vinegar and old tallow.

"You see, Edward? The ledger must preserve the harmony of the procedure. The Alderman does not read the parish registers to discover that men die; he knows that already from the bells. He reads to assure himself that they die legally, under the care of a licensed person, and according to the ancient statutes of the realm. If we wrote down that the man expired because his heart was like a dried walnut and we took the last drop of grease out of his arm, the Court of Assistants would hold an inquiry that would last until Michaelmas. But restorative rest—that is an academic category. No one can dispute an academic category."

"And the Searchers?" Ned asked, nodding toward the door where the heavy bolt still sat cold and fixed in its staples. "What do we tell them when they come with the red wand?"

"We tell them," Plume said, rising and reaching for his jar of dried scorpions, which he kept for the compounding of his sovereign cordial, "that Master Clout has concluded his business with the Corporation, and that we are now ready for Bed Number Five."

He looked down the long, dim ward, where forty-six shadows shifted under the greasy light, each one waiting for its turn to be preserved upon the vellum before the ink ran dry.

"Fetch the vinegar-cloth, Edward," the Doctor said, his voice regaining its thin, metallic authority. "The air in this corner has a decidedly melancholic weight. We must clarify the room before we open the next arm, or we shall have the whole ward thinking they are permitted to die without an order from the vestry."

The vinegar-cloth was three weeks out of date, having been steeped in an infusion of sour cider and dead flies during the late Queen’s funeral, but it possessed sufficient civic authority to make Doctor Plume sneeze four times into his beaver hat.

"The lungs are purifying themselves," Plume wheezed, wiping his weeping eyes with the corner of his lace cuff. "A salutary discharge. The volatile acid of the pickling brine cuts the putrid thickness of the ward like a cleaver through suet. Mark that, Edward: when the physician sneezes, the ambient pestilence trembles. It is an axiom of the Bolognese school."

"I marked it, Master," Ned said, standing by Bed Number Five with the brass scraper and a cracked pipkin. "I also marked that you sneezed directly into the candle, and now the tallow smells of wet hair. If the ambient pestilence trembles, it is only because it fears being greased to death before midnight."

Bed Number Five contained one Barnaby Rudge, a cordwainer from Bermondsey Street, who had spent the thirty years prior to the pestilence hammering neat’s-leather soles for the watermen and drinking stale bracket behind the parish church. This double discipline had left him with a skin the color of an old parsnip and an abdomen that rose beneath his greasy flannel shirt like a half-baked loaf of rye. He was not staring at the ceiling as the late chandler had done; he was glaring at Doctor Plume with the furious, bloodshot intensity of an ox that has caught scent of the shambles.

"No knives," the cordwainer growled. His voice had the dry, rattling scrape of a shovel dragging over gravel. "You bled my cousin Simkins on Michaelmas Eve, Doctor, and by the feast of Saint Faith his legs were as flat as two salt-herrings and he could not whistle for his dog. Keep your irons in your pocket, or I will take that brass spoon of yours and shove it down your Latin gullet."

Plume drew himself back toward the aisle, his thin fingers clutching the pomander as if it were a weapon of defense. He tilted his chin until his ruff pressed against his throat, producing a double fold of yellowed skin that resembled the comb of an elderly turkey.

"The patient is furious," Plume whispered to Ned with an academic air that barely masked his instinct to retreat toward the hearth. "Observe the tension of the masseter muscles, Edward. The unprovoked hostility toward the representative of the Crown and the Faculty. This is not natural perversity; it is yellow bile. Choler in its most virulent and combustible manifestation. It has mounted from the gall-bladder along the biliary conduits, entered the great meseraic veins, and is currently scorching the lower rim of his intellect."

"He doesn't like having his throat cut for fourpence, Master," Ned observed, setting the pipkin on the floor. "It doesn't take much Greek to make a man object to a fleam."

"It is pure choler, I tell you," Plume insisted, raising his voice so that several patients in the neighboring pallets began to grope frantically for their rosaries, evidently under the impression that the Last Trumpet was being sounded by a man with a Cambridge accent. "A choleric man is like a chimney choked with soot; the smallest spark of contradiction sets him in a blaze. Galen, in his seventh treatise on the Temperaments, observes that a shoemaker in a fever is three times more perilous than a trooper with a caliver, for his blood is naturally heated by the perpetual friction of his awl."

Plume stepped forward again, though he prudently kept the pine-plank frame of Bed Number Six between his silk hose and the cordwainer’s twitching boots. He produced his small bone spatula and pointed it at the man’s nose.

"Master Rudge," the doctor intoned, "you are an engine of fire. Your heart is an over-stewed pot; your spleen is dry as an autumnal leaf; and if we do not immediately draw off this sulfurous humor through the inferior portals, your brain will curdle before the third watch. We are not going to bleed you. You are unworthy of phlebotomy. Blood is a noble fluid, the seat of the vegetative spirit; you have scarcely enough of it left to grease a boot-heel. What you require is an authoritative evacuation of the yellow superfluity."

The cordwainer spat into the straw. The discharge was a violent, saffron hue, resembling nothing so much as a spoonful of mustard mixed with ditch-water.

"There!" cried Plume, skipping backward two paces and nearly planting his buckled shoe into Gudge’s barley-water pot. "Did you witness the projection? Did you note the tincture? Pure vitelline bile, the very color of a crow’s egg when the yolk has turned. Edward, the purging-jar. We must administer the Electuarium de Succo Rosarum combined with five drachms of scammony from Aleppo."

Ned did not move toward the medicine chest. He remained leaning against the bedpost, looking down at the shoemaker with a cool, measuring eye that had seen more men emptied of their insides than the Southwark butchers had hogs.

"We have no scammony, Master," Ned said flatly. "The apprentice to the sign of the Golden Mortar traded our scammony to a French sailor last Tuesday for three lemons and a parrot that died of the pip before they reached Deptford. All we have in the purging drawer is four ounces of powdered rhubarb that has been eaten by weevils and a pot of black treacle that the beadle’s boy sat upon during the proclamation."

"Rhubarb will suffice," Plume said, waving his hand as if dismissing an empire. "Rhubarb is of an astringent and drying property, yet possessed of a secret virtue whereby it gently attracts the yellow humors and carries them down through the intestine without exasperating the bladder. Bring the pot. Mix it with two spoons of the vinegar-cider to correct the wind."

"The cordwainer doesn't have wind, Master," Ned remarked, still unmoving. "He has an ague in his belly that makes him rattle like a dry gourd, and he hasn't passed anything thicker than pump-water since the bells began ringing for the new king."

"Insolence!" Plume snapped, though he lowered his voice lest the shoemaker hear the administrative difficulty. "Are we to consult the patient upon the nature of his own excreta? The vulgar are notoriously incompetent observers of their own interior geography. They imagine that because their belly rumbles, they are empty; whereas the philosopher knows that a rumbling belly is merely the voice of the yellow humor disputing the mastery with the melancholic sediment. Mix the rhubarb, boy. And add a drachm of the powdered stag-horn to strengthen the cardiac orifices."

Ned sighed, a long, weary exhalation that stirred the greasy fuzz on his sheepskin jerkin. He walked back to the scrubbed pine table where the medicine chest sat gaping like the mouth of an open grave. The chest had nine drawers, each labeled in faded gilt letters that had once been Latin: Rad. Bryoniae, Scilla, Theriaca, Helleborus Niger. Most of them contained only dust, dried rat-pellets, and bits of string that Plume had saved from parcels sent down from Bishopsgate.

From the bottom drawer, Ned extracted a small earthenware jar that smelled intensely of ancient leather and dried cabbage. The rhubarb powder inside had gathered into hard, grayish lumps like sparrow droppings. He took up the heavy iron pestle and ground them against the unglazed side of the jar with a screech that caused Master Gudge to look up from his toenails with a momentary expression of theological alarm.

"Is the carriage ready, Ned?" the deaf nurse shouted across the room, his red nose glowing like an ember in the murky air. "The dead-cart usually comes by the second bell, if the horse hasn't fallen in the ditch by the churchyard."

"Get back to your barley, Gudge," Ned said without shouting. It was useless to shout; Gudge only heard what he could turn into an extra quart of ale.

Ned took the pewter spoon, dipped it into the brown mess, and walked back to Bed Number Five. The shoemaker had pulled his knees up toward his chest, his yellow face twisted into an expression of profound misery that Plume was already recording in his mental register as Symptoma Cholerica Tertia.

"Open your mouth, Master Rudge," Ned said, holding the spoon level. "It tastes like the bottom of a dyer’s vat, but if you swallow it quick, you won't have to listen to the Doctor explain what it’s doing to your liver."

"I won't have it," Rudge gasped, clenching his teeth until his jaw-muscles stood out like cords. "It’s horse-physic. You gave that stuff to the cooper's lad on Friday, and he didn't stop running until they laid him in the lime-pit."

"The cooper’s lad," Plume intervened, stepping forward with his arms folded across his rabbit-fur trim, "died of a suppression of the animal spirits occasioned by his obstinate refusal to sweat after the evacuation. His humors were exceedingly unmanageable—a gross, pituitous stock with an accidental admixture of adust blood. Your case is entirely different. You are simple choler. A dry, hot, noble disease. A disease proper to an artisan of the better class. Swallow the electuary, my good man, and we shall have your bile as clear as Rhenish wine before the dawn."

Ned didn't wait for the logic to take effect. With a practiced movement that had been perfected on forty unruly weavers during the August heat, he brought his left thumb down sharply upon the soft tissue beneath the cordwainer’s jaw, right where the angular artery crossed the bone. Rudge’s mouth flew open with a choked gasp of outrage, and Ned tipped the gray, acidic paste straight over the root of the tongue, following it with a decisive upward thrust under the chin that forced the swallow before the man could spit it into his eyes.

The shoemaker’s eyes bulged. His skin turned from parsnip to the color of wet lead. He made three distinct clicking noises in his gullet, seized the edges of his pallet with hands that were as black as shoemaker's pitch, and shuddered from his wool stockings to his greasy nightcap.

"The operation begins," Plume said with great satisfaction, taking out his silver watch—a massive bulb of turnip-shaped metal that ticked with the violence of a water-mill. "Notice the immediate pale tint of the skin, Edward. The cold sweat upon the forehead. That is the rhubarb entering into a philosophical combat with the yellow vapor. The vegetable power is driving the elemental heat from the center toward the circumferences."

"It's driving his stomach into his throat, is what it's doing," Ned said, reaching for the brass basin and holding it under Rudge’s chin. "Get back, Master. He's got a three-foot reach and the wind is coming around from the river."

The cordwainer did not vomit; the rhubarb was too heavy and dry to permit of so clean an exit. Instead, an enormous, hollow rumble issued from beneath his flannel shirt, like the sound of an iron-shod dray passing over a cellar grating. A neighboring patient, an old woman who had been murmuring the fifty-first Psalm in her sleep, suddenly sat bolt upright, shrieked "The Spaniards are upon us!" and fell back onto her bolster with her eyes fixed on the rafters.

"Superb," Plume murmured, taking the goose quill from his hat-band. "An exemplary motion of the intestine. The peristaltic wave is descending in strict accordance with the rules laid down by Fallopius in his lectures at Padua. The choler is dislodging itself from the internal folds. Edward, make an entry: To Master Rudge, a portion of the Catholic Root, whereby the combust bile was provoked into an obedient descent."

"He's not descending, Master," Ned said, watching the shoemaker’s toes curl until the seams of his stockings split. "He’s stiffening. Look at his thumbs."

The shoemaker’s thumbs were turned sharply inward across his palms, locked in the rigid spasm of a man whose nerves have suddenly taken offense at what has been put into them. His breath came in short, dry puffs that smelled powerfully of the sour vinegar and the ancient dust of the bottom drawer.

"A cramp merely," Plume said, though he didn't step any closer to the pallet. "An accidental constriction of the tendinous extremities, caused by the sudden evacuation of the fiery spirit. In such cases, the ancient method is clear: we must apply a counter-irritant to the soles of the feet to draw the nervous fluid back from the center."

"We don't have any counter-irritants," Ned said. "Unless you want to use the hot brick that Gudge has been sitting on to keep his ham-bones warm."

"The nurse’s brick will do admirably," Plume said, brightening. "Provided it has attained a proper degree of caloric saturation. Gudge! Gudge, you ancient blockhead! Deliver the brick!"

Gudge, who had finished his toenails and was now engaged in peeling a small, wrinkled onion with the same knife, looked up with an expression of mild annoyance.

"What say?" the old man shouted, his voice echoing off the damp boards of the warehouse. "The cart’s not here yet! I told you, he won't come down Horseshoe Alley until he’s finished his pot at the Nag’s Head! He says the lane is too narrow for two horses when the plague-tents are up!"

"The brick, man!" Plume screamed, pointing with his spatula toward the hearth. "The warm brick from under your buttocks! The shoemaker is in a convulsion!"

Gudge blinked, looked down between his thighs, and slowly extracted an ancient, soot-blackened paving tile that had been absorbing his personal heat for the better part of four hours. He wiped it with the sleeve of his coat, which did not make it any cleaner, and held it out at arm's length with the indifferent grace of a servant presenting a dish of mutton.

"It's not very warm," Gudge said. "The fire went out when the rain came down the chimney at six o'clock. It’s about as warm as an old dog’s nose, but it’s dry. The smith didn't want it, so I had it."

Ned took the brick. It was lukewarm and possessed an odor that was entirely its own, compounded of wood-ash, stale grease, and parish linen. He laid it against the soles of Rudge’s wool stockings, but the shoemaker gave no sign of noticing the application. His eyes were wide and fixed, reflecting the tiny, guttering flame of the tallow-candle with a glassy, yellow sheen that looked remarkably like varnish.

"He doesn't feel it, Master," Ned said. He reached down and touched the man’s throat. The skin was no longer hot like an old brick; it was cool and damp, with that particular slickness that comes over neat's-leather when it has been left in a gutter overnight. "His furnace is going out. You've purged the heat right out of his vessel."

"Impossible," Plume said, though his voice had dropped back into that thin, rapid register he used when the Alderman’s officers came to check the balance of the poor-box. "The quantity was moderate. Three drachms of rhubarb cannot extinguish the natural heat of an adult cordwainer. It is contrary to every proposition in the second book of Galen’s Therapeutics. The man is simply stubborn. The inhabitants of Bermondsey are notorious for their sluggish response to rational physics; their bodies are hardened by their trade, their membranes thickened by the breathing of tanners' dung."

Plume took a step closer, held his pierced walnut-shell under his nose with his left hand, and with his right reached out to touch the shoemaker’s forehead with the very tip of his lancet handle.

"Master Rudge," the doctor whispered. "Exert the will. The faculty has cleared the path. The yellow humor is dispersed. You have only to command the vital spirits to resume their seats."

Master Rudge did not command his spirits. Instead, his jaw dropped with a dry, wooden snap, and a long, whistling puff of air came from his gray lips. It sounded like the air escaping from a pair of leaky bellows in an empty forge.

After that, the infirmary was very quiet, save for the old woman who was now trying to bite her own bolster, and the steady, indifferent drip of the rainwater falling through the pigeons' thatch onto the late tallow-chandler's pillow in Bed Number Four.

"Well," Ned said, standing up and wiping his hands on his breeches. "The yellow bile is quiet enough now. It won't give the Company any more trouble tonight."

Plume stood for several moments with his spatula raised in the air, like an orator who has been interrupted by an earthquake and is waiting for the ground to settle before concluding his period. His ruff had begun to wilt in the river-damp, the starch giving way until the outer folds drooped over his shoulders like the petals of a dead lily.

"A remarkable termination," the doctor said at last, his voice steadying itself by sheer force of long practice in the London wards. "A distinct case of Apoplexia Cholerica. The yellow humor, finding itself driven from the lower belly by the superior virtue of the medicine, made a desperate and sudden ascent along the great arteries, overleaped the diaphragmatic barrier, and overwhelmed the seat of the soul in the third ventricle. It is a known complication. It was described by Mercurialis in his discourse upon the pestilence of Venice."

"He was just an old cobbler who took a bellyful of your dead rhubarb on an empty stomach, Master," Ned said, reaching for his piece of chalk.

"Edward," Plume said, and his voice was suddenly very sharp. "Do you see this gown?"

"I see it, Master. It's missing three buttons and the lining is coming out at the arm-pit."

"This gown was worn by my uncle before the Court of Assistants in the guildhall of the City of London. It has been present at forty-six post-mortem dissections and two coronations. It represents the wisdom of antiquity, confirmed by royal charter, and preserved from the ignorant innovations of weavers, apothecaries, and parish apprentices. If a man dies under the care of this gown, he dies according to the laws of nature and the King’s peace. If he dies under your interpretation, he dies like a dog in a ditch, without benefit of the categories."

Ned paused with the chalk an inch above the floorboards. He looked at the white marks—forty-five of them now, if he rubbed out the cobbler. Then he looked at Plume, whose small, watery eyes were blinking furiously behind his vinegar-stained spectacles.

"I'm not disputing the categories, Master," Ned said mildly. "I'm just keeping the tally. If I don't keep the tally right, the carter will charge the parish for forty-seven when he’s only carrying forty-five, and then the churchwardens will have the difference out of our wages when the quarantine is drawn."

"The tally must be preserved, certainly," Plume agreed, returning to the pine table and taking up his quill with an air of renewed dignity. "A correct administration is the true medicine of the commonwealth. Let the cobbler be entered under his proper title: Barnaby Rudge, cordwainer. Visited at the ninth hour with a vehement suffocation of yellow bile. Administered the sovereign cathartic of Alexandria. The gross parts having been expelled, the patient succumbed to a sudden defect of the radical moisture, occasioned by the alignment of Saturn with the tail of the Dragon."

"Saturn isn't in the Dragon, Master," Ned said, leaning over the ledger. "It's in the Fish. You told the parson so yourself on Monday when he asked if he ought to take his shirts to Epping."

"The Dragon’s tail is extensive, Edward," Plume replied without looking up from his writing. "It covers a great deal of territory in Southwark. A physician must allow for the local topography when drawing up an astrological certificate. Saturn in the Fish produces dropsies; Saturn in the Dragon produces apoplexy. Would you have the Alderman think our patients are dying of a common dropsy, like so many draymen who have fallen into the dock? No, apoplexy is the only proper designation for a man of Rudge's substance. He was a master of his company; he had two journeymen and an iron knocker on his shop door. We must show some respect for the civic orders."

The doctor completed the flourish at the end of the name, took up his pounce-pot—which was filled with crushed egg-shells and river-sand—and sprinkled it over the wet ink. He blew the surplus across the table, where it settled like a gray frost over his fleams and his lancets.

"Now," Plume said, rising and taking his pomander between two fingers once more. "The air is somewhat lighter in the center of the aisle. The yellow humor has evidently dispersed into the rafters. What is the condition of Bed Number Six?"

Ned didn't need to look at his list. Bed Number Six was situated immediately beneath the middle roof-slit, where the sheep’s-fat had peeled away from the wicker frame, allowing a thin, constant stream of gray Southwark fog to drift down into the room like smoke from a lime-kiln.

"Bed Number Six is an old woman from St. Mary Overy," Ned said. "She was brought in on a hand-barrow by four watermen who were so drunk they dropped her twice on the stone steps. She has a swelling under her left ear as big as a goose egg, and she hasn't said anything since noon except that she wants her small brass kettle brought to her from the cellar."

Plume paused, his hand hovering over his instrument-case. He cocked his head, listening to the various sounds that drifted through the murky gloom of the ward: the wet, bubbling breath of a dyer three beds down; the dry scratching of a rat behind the wainscot; and the distant, heavy thud of the watchman’s halberd striking the pavement outside the locked door to let the neighborhood know that the parish was still secure against the dead.

"A swelling under the ear," the doctor repeated thoughtfully. "The parotid gland. That is an ambiguous territory, Edward. It may be the true plague-bubo, which, as you know, requires the immediate application of a dried toad to draw out the arsenic; or it may be merely a rebellious flux of phlegm from the brain-pan, occasioned by her sleeping near the water-stairs without a woollen caul."

"She isn't wearing a caul," Ned said. "She isn't wearing much of anything except an old woollen petticoat that the watermen didn't think was worth the trouble of stripping off her."

"Then it is almost certainly phlegm," Plume declared, his spirits visibly rising as he found himself back upon the solid ground of academic distinction. "The female sex is naturally cold and moist, like an unbaked pasty. When exposed to the nocturnal air of the river, their internal cavities fill with a thick, white, ropy slime which, finding no exit through the nostrils, precipitates into the spongy tissues of the neck. It is a simple mechanical congestion. We shall treat her with the great hot ammoniac plaster, followed by a mild decoction of hyssop and dried figs."

"We don't have any figs, Master," Ned reminded him, his voice dropping into that rhythmic monotone he used when listing the infirmary's deficiencies. "We have the rhubarb that killed Rudge, the pig's bladder, three pints of vinegar that has turned to mother, and the tail-end of a salt ling that Master Gudge has been hiding under his mattress to eat on Friday."

Doctor Plume did not appear to hear him. He was already adjusting his spectacles, peering through the dim, smoky air toward Bed Number Six with that expression of high, philosophical determination that had already cost the parish of Saint Jude-in-the-Muck two chandlers, a blacksmith, and forty yards of good linen shroud.

"The art," Plume said, stepping over the puddle of cold barley-water that had leaked from Gudge's pot, "does not consist in the abundance of the materials, Edward. The art consists in the application of the method. Where there are no figs, the physician must use his invention; where there is no ammoniac, he must rely upon the native resources of the parish. Bring the small shears and the vinegar-sponge. If her phlegm proves obstinate, we shall be forced to scarify the neck, and that, as you know, requires a steady hand and a clear light."

"The light is going, Master," Ned said, pointing with his chalk to the three tallow dips that were now guttering in their pools of mutton-grease along the pine table. "The watch won't give us any more candles until tomorrow noon, and the grease is running down the legs like butter."

"Then we must work with greater celerity," Plume said, his eyes glittering behind the spotted glass. "A physician with a lancet can find an artery in the dark, Edward. The vessel cries out to the steel; the blood recognizes the hand of the Master. Hold the dish, boy. And see that Master Gudge does not fall asleep upon that paving tile again; if the brick cools entirely, we shall have no means of warming the lancet-edge before we begin upon the parotid."

Ned picked up the notched pewter bowl, its surface still greasy from the chandler’s last three tablespoons of blood. He took one look back at Bed Number Five, where Barnaby Rudge lay with his thumbs turned in and his parsnip face turned up toward the leaking thatch, and then followed the rustling skirt of Plume's rabbit-fur gown down into the dark.