From his discussions with Dr Simpson he knew that the concept of ovariotomy was contentious enough – some even suggesting that the opening of the abdomen to remove an ovarian cyst was tantamount to homicide – but this was more contentious still.

He had thought about summoning help. Another practitioner more experienced than he was. A surgeon. Another obstetrician. But he hesitated. They might not agree with his plan of action, might attempt to prevent him doing what he wanted to do, what he felt he must do in the circumstances.

He wondered what Dr Simpson would do in his place, but couldn’t convince himself that he would agree with Raven’s somewhat reckless plan of action. The opinions of other obstetricians were not encouraging either. Some of his reading on the subject was, in retrospect, more hindrance than help. Charles Meigs, the eminent American obstetrician, had discussed the management of tubal pregnancy as a hopeless endeavour: ‘We could make an incision in the abdomen and clear away the coagula and serum. But who is bold enough to do so? Who is astute enough to discriminate betwixt all possible causes of such phenomena to warrant him in the performance of gastrotomy for fallopian pregnancy? There is no such wise and bold surgeon. Nothing remains but for us to extend all relief and calmly await and submit to the inevitable end.’

No such wise and bold surgeon? Not wise perhaps. But bold certainly. Especially if the alternative was to stand by and watch Sarah die. Calmly submit to the inevitable end? Such a thing was not possible.

‘Martha, she is bleeding,’ Raven said as calmly as he could, despite a sense of rising panic. ‘The only way to save her is to open the abdomen and arrest the haemorrhage.’

Martha looked appalled by this suggestion. ‘Are you sure?’

The question caused him to ask himself how certain he was about the diagnosis. He went through the symptoms and signs again. No menstruation for eight weeks, recurrent pain and then collapse. She was pale and cold, with a weak pulse. There was a considerable amount of effusion in the abdomen. However, there was no way of knowing for sure, no way to confirm it without actually going in. The only alternative would be to wait until she was dead and confirm his diagnosis at post-mortem, as had been the case in Paris, and that he was not prepared to do. Not again. It was always better to do something than nothing.

He had to act, and he must do so immediately if she was to have any chance of survival. The fallopian tube and its vessels would be secured and divided in much the same way as during an ovariotomy, as he had done when he removed the ovarian cyst from Mrs Glassford’s abdomen post mortem. The operation itself should be relatively straightforward. The result, however, would be quite another matter.