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Big Data Analytics and Machine
Intelligence in Biomedical
and Health Informatics
 Scrivener Publishing
100 Cummings Center, Suite 541J
Beverly, MA 01915-6106

Publishers at Scrivener
Martin Scrivener ([email protected])
Phillip Carmical ([email protected])
Big Data Analytics and Machine
Intelligence in Biomedical
and Health Informatics

Concepts, Methodologies,
Tools and Applications

Edited by
Sunil Kumar Dhal
Subhendu Kumar Pani
Srinivas Prasad
and

Sudhir Kumar Mohapatra

This edition first published 2022 by John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
and Scrivener Publishing LLC, 100 Cummings Center, Suite 541J, Beverly, MA 01915, USA
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 Contents

Preface xiii
1 An Introduction to Big Data Analytics Techniques in Healthcare 1
Anil Audumbar Pise
1.1 Introduction 1
1.2 Big Data in Healthcare 3
1.3 Areas of Big Data Analytics in Medicine 5
1.3.1 Genomics 6
1.3.2 Signal Processing 7
1.3.3 Image Processing 8
1.4 Healthcare as a Big Data Repository 9
1.5 Applications of Healthcare Big Data 10
1.5.1 Electronic Health Records (EHRs) 10
1.5.2 Telemedicine 11
1.5.3 NoSQL Database 12
1.5.4 Framework for Reconstructing Epidemiological
Dynamics (FRED) 12
1.5.5 Advanced Risk and Disease Management 13
1.5.6 Digital Epidemiology 13
1.5.7 Internet of Things (IoT) 13
1.5.7.1 IoT for Health Insurance Companies 14
1.5.7.2 IoT for Physicians 14
1.5.7.3 IoT for Hospitals 15
1.5.7.4 IoT for Patients 15
1.5.8 Improved Supply Chain Management 16
1.5.9 Developing New Therapies and Innovations 16
1.6 Challenges in Big Data Analytics 16
1.7 Big Data Privacy and Security 17
1.8 Conclusion 18
1.9 Future Work 18
References 18

v
vi Contents

2 Identify Determinants of Infant and Child Mortality Based

Using Machine Learning: Case Study on Ethiopia 21
Sudhir Kumar Mohapatra, Srinivas Prasad,
Getachew Mekuria Habtemariam and Mohammed Siddique
2.1 Introduction 22
2.2 Literature Review 23
2.3 Methodology and Data Source 25
2.3.1 Study Area 26
2.3.2 Source of Data 26
2.3.3 Variables Included in the Study 26
2.3.4 Building a Predictive Model 26
2.4 Implementation and Results 28
2.4.1 Missing Value Handling 30
2.4.2 Feature Selection Methods 30
2.4.3 Features Importance Rank 31
2.4.4 Data Split 31
2.4.5 Imbalanced Data Handling 33
2.4.6 Make Predictions on Unseen Test Data 35
2.4.6.1 Naïve Bayes Classifier: Prediction on Test Data 35
2.4.6.2 C5.0 Classifier on Train Dataset 37
2.4.6.3 Rules From Decision Trees 38
2.4.6.4 SVM Classifier: Unbalanced and Balanced
Train Dataset 39
2.4.6.5 Random Forest Model: On Train Dataset 41
2.4.7 Evaluation 42
2.5 Conclusion 44
References 44
3 Pre-Trained CNN Models in Early Alzheimer’s Prediction
Using Post-Processed MRI 47
Kalyani Gunda and Pradeepini Gera
3.1 Introduction 48
3.1.1 Background 48
3.2 Experimental Study 51
3.2.1 OASIS Longitudinal Data 51
3.2.1.1 Feature Characteristics 52
3.2.2 Alzheimer’s 4-Class-MRI-Dataset 54
3.3 Data Exploration 55
3.3.1 Features Description 55
3.4 OASIS Dataset Pre-Processing 61
 Contents vii

3.4.1 Features Selection 62

3.4.2 Feature Transform 62
3.4.2.1 MinMaxScaler 63
3.4.3 Model Selection 64
3.4.3.1 Decision Tree Classification 64
3.4.3.2 Ensemble Machine Learning 65
3.4.3.3 Random Forest Classifier 65
3.4.4 Model Fitting 66
3.4.5 Evaluation Metric/Model Evaluation 67
3.5 Alzheimer’s 4-Class-MRI Features Extraction 69
3.6 Alzheimer 4-Class MRI Image Dataset 69
3.6.1 Image Processing 69
3.6.2 Classification of 4-CLASS-MRI 71
3.6.2.1 AlexNet 74
3.6.2.2 VGG-16 75
3.6.2.3 Inception (GoogLeNet) 76
3.6.2.4 Residual Network (“RESNET”) 77
3.6.2.5 MobileNetV2 78
3.6.2.6 NASANet (Neural Architecture Search
Network) 79
3.7 RMSProp (Root Mean Square Propagation) 80
3.8 Activation Function 81
3.9 Batch Normalization 81
3.10 Dropout 81
3.11 Result—I 82
3.11.1 Result—II 84
3.12 Conclusion and Future Work 89
Acknowledgement 89
References 90
4 Robust Segmentation Algorithms for Retinal Blood Vessels,
Optic Disc, and Optic Cup of Retinal Images in Medical Imaging 97
Birendra Biswal, Raveendra T., Dwiti Krishna Bebarta,
Geetha Pavani P. and P.K. Biswal
4.1 Introduction 98
4.2 Basics of Proposed Methods 100
4.3 Experimental Results and Discussion 107
4.4 Conclusion 115
References 116
viii Contents

5 Analysis of Healthcare Systems Using Computational

Approaches 119
Hemanta Kumar Bhuyan and Subhendu Kumar Pani
5.1 Introduction 120
5.1.1 Diagnosis Process in Healthcare Systems 120
5.1.2 Issues of Healthcare 120
5.1.3 Clinical Diagnosis Based on Soft Computing 122
5.1.3.1 Neural Network and Fuzzy Healthcare
Systems 122
5.1.3.2 Systems of Fuzzy-Genetic Algorithms
(F-GA) 123
5.1.3.3 Genetic Algorithm Systems and Neural
Networks (NNGA) 123
5.1.3.4 Genetic Algorithm, Fuzzy Logic and Neural
Network (NN-FL-GA) 123
5.1.3.5 Tool for Big Data Analytics 124
5.2 AI & ML Analysis in Health Systems 124
5.3 Healthcare Intellectual Approaches 127
5.3.1 AI and ML Roles in the Healthcare System 127
5.3.2 Medical ML Medicine 129
5.3.3 Clinical System Growth 130
5.3.4 Clinical Data Development Using AI 130
5.3.5 EHR Disease Detection 130
5.3.6 Cognitive Cancer Approaches 130
5.3.7 Effective EHR Operations 131
5.3.8 Deep Learning Approach (DL) in the Clinical System 131
5.3.9 Healthcare Data Transformation 131
5.3.10 Prediction of Cancer 133
5.4 Precision Approaches to Medicine 133
5.4.1 EMR Analysis Medicine 133
5.4.2 AI-Based Medicine Accuracy 134
5.4.3 Tumor Cell Visual Evaluation 134
5.5 Methodology of AI, ML With Healthcare Examples 134
5.6 Big Analytic Data Tools 136
5.6.1 Hadoop-Based Health Industry Tools 138
5.6.2 Healthcare System Architecture 138
5.7 Discussion 141
5.8 Conclusion 142
References 143
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 Contents ix

6 Expert Systems in Behavioral and Mental Healthcare:

Applications of AI in Decision-Making and Consultancy 147
Shrikaant Kulkarni
6.1 Introduction 148
6.2 AI Methods 149
6.2.1 Machine Learning & Artificial Neural Networks
(ML & ANN) 149
6.2.2 Natural Language Processing (NLP) 151
6.2.3 Machine Perception & Sensing 152
6.2.4 Affective Computing 152
6.2.5 Virtual & Augmented Reality (VR & AR) 153
6.2.6 Cloud Computing & Wireless Technology 154
6.2.7 Robotics 154
6.2.8 Brain–Computer Interfaces (BCIs) 154
6.2.9 Supercomputing & Simulation of Brain 155
6.3 Turing Test 156
6.4 Barriers to Technologies 157
6.5 Advantages of AI for Behavioral & Mental Healthcare 157
6.6 Enhanced Self-Care & Access to Care 158
6.6.1 Care Customization 158
6.6.2 Economic Benefits 159
6.7 Other Considerations 160
6.8 Expert Systems in Mental & Behavioral Healthcare 161
6.8.1 Historical Perspectives 162
6.9 Dynamical Approaches to Clinical AI and Expert Systems 165
6.9.1 Temporal Modeling 165
6.9.2 Practical Global Clinical Applications 165
6.9.3 Multi-Agent Model Dedicated to Personalized
Medicine 167
6.9.4 Technology-Enabled Clinicians 168
6.9.5 Overview of Dynamical Approaches 168
6.9.6 Cognitive Computing in Healthcare 169
6.9.7 Emerging Technologies & Clinical AI 171
6.9.8 Ethics and Futuristic Challenges 172
6.10 Conclusion 173
6.11 Future Prospects 175
References 176
x Contents

7 A Mathematical-Based Epidemic Model to Prevent

and Control Outbreak of Corona Virus 2019 (COVID-19) 187
Shanmuk Srinivas Amiripalli, Vishnu Vardhan Reddy Kollu,
Ritika Prasad and Mukkamala S.N.V. Jitendra
7.1 Introduction 188
7.1.1 Corona Viruses 188
7.1.2 Epidemiological Modeling Using Graph Theory 189
7.2 Related Work 189
7.3 Proposed Frameworks 190
7.3.1 Infection Spreading Model 190
7.3.2 Relation between Recovery Time and Interaction
of Antivirus Nodes 191
7.3.3 Proposed Algorithm 192
7.3.4 Detail Explanation of Algorithm 193
7.4 Results and Discussion 194
7.5 Conclusion 201
References 201
8 An Access Authorization Mechanism for Electronic Health
Records of Blockchain to Sheathe Fragile Information 205
Sowjanya Naidu K. and Srinivasa L. Chakravarthy
8.1 Introduction 206
8.1.1 Basics of Blockchain Technology 206
8.1.2 Distributed Consensus Protocol 209
8.1.3 Smart Contracts 211
8.1.3.1 How Do Smart Contracts Work? 211
8.1.4 Ethereum and Smart Contracts 212
8.2 Related Work 212
8.3 Need for Blockchain in Healthcare 216
8.4 Proposed Frameworks 219
8.5 Use Cases 223
8.6 Discussions 229
8.7 Challenges and Limitations 231
8.8 Future Work 231
8.9 Conclusion 232
References 233
9 An Epidemic Graph’s Modeling Application to the COVID-19
Outbreak 237
Hemanta Kumar Bhuyan and Subhendu Kumar Pani
9.1 Introduction 237
 Contents xi

9.2 Related Work 239

9.3 Theoretical Approaches 240
9.3.1 Graph Convolutional Networks 241
9.3.2 Recurrent Neural Networks 241
9.3.3 Epidemic Modeling 242
9.4 Frameworks 243
9.4.1 Use the Data Model 243
9.4.2 Problem Formulation 244
9.4.3 Proposed Architecture 244
9.5 Evaluation of COVID-19 Outbreak 246
9.5.1 Used Datasets 246
9.5.2 Evolving an Epidemic 246
9.5.3 Predicted Analysis of the Infected Individuals 250
9.6 Conclusions and Future Works 250
References 252
10 Big Data and Data Mining in e-Health: Legal Issues
and Challenges 257
Amita Verma and Arpit Bansal
Object of Study 257
10.1 Introduction 258
10.2 Big Data and Data Mining in e-Health 260
10.3 Big Data and e-Health in India 262
10.4 Legal Issues Arising Out of Big Data and Data Mining
in e-Health 263
10.4.1 Right to Privacy 264
10.4.2 Data Privacy Laws 265
10.4.3 Liability of the Intermediary 270
10.5 Big Data and Issues of Privacy in e-Health 271
10.6 Conclusion and Suggestions 272
References 273
11 Basic Scientific and Clinical Applications 275
Manna Sheela Rani Chetty and Kiran Babu C. V.
11.1 Introduction 275
11.2 Case Study-1: Continual Learning Using ML for Clinical
Applications 283
11.3 Case Study-2 286
11.4 Case Study-3: ML Will Improve the Radiology Patient
Experience 289
xii Contents

11.5 Case Study-4: Medical Imaging AI with Transition from

Academic Research to Commercialization 292
11.6 Case Study-5: ML will Benefit All Medical Imaging ‘ologies’ 295
11.7 Case Study-6: Health Providers will Leverage Data Hubs
to Unlock the Value of Their Data 298
11.8 Conclusion 300
References 301
12 Healthcare Branding Through Service Quality 305
Saraju Prasad and Sunil Dhal
12.1 Introduction to Healthcare 305
12.2 Quality in Healthcare 307
12.2.1 Developing Countries Healthcare Service Quality 308
12.2.2 Affordability of Quality in Healthcare 308
12.2.3 Dimensions of Healthcare Service 309
12.2.4 Healthcare Brand Image 309
12.2.5 Patients’ Satisfaction 310
12.2.6 Patients’ Loyalty 310
12.3 Service Quality 311
12.3.1 Patient Loyalty with Service Quality in Healthcare 312
12.3.2 Healthcare Policy 313
12.4 Conclusion and Road Ahead 315
References 316
Index 321
 Preface

Introduction
The novel applications of Big Data Analytics and machine intelligence in
biomedical and healthcare sector can be regarded as an emerging field in
computer science, medicine, biology application, natural environmental
engineering, and pattern recognition. The use of various Data Analytics
and intelligence techniques are nowadays successfully implemented in
many healthcare sectors. Biomedical and Health Informatics is a new era
that brings tremendous opportunities and challenges due to easily avail-
able plenty of biomedical data. Machine learning presenting tremendous
improvement in accuracy, robustness, and cross-language generalizabil-
ity over conventional approaches. The aim of healthcare informatics is to
ensure the high-quality, efficient healthcare, better treatment and quality
of life by efficiently analyzing the abundant biomedical, and healthcare
data. Earlier, it was common requirements to have a domain expert to
develop a model for biomedical or healthcare; but now the patterns are
learned automatically for prediction. Due to the rapid advances in intel-
ligent algorithms have established the growing significance in health-
care data analytics. The IoT focuses to the common idea of things that
is recognizable, readable, locatable, controllable, and addressable via the
Internet. Intelligent Learning aims to provide computational methods for
accumulating, updating and changing knowledge in the intelligent systems
and particularly learning mechanisms that help us to induce knowledge
from the data. It is helpful in cases where direct algorithmic solutions are
unavailable, there is lack of formal models, or the knowledge about the
application domain is inadequately defined. In Future Big data analytics
has the impending capability to change the way we work and live. With the
influence and the development of the Big Data, IoT concept, the need for

xiii
xiv Preface

AI (Artificial Intelligence) techniques has become more significant than

ever. The aim of these techniques is to accept imprecision, uncertainties
and approximations to get a rapid solution. However, recent advance-
ments in representation of intelligent system generate a more intelligent
and robust system providing a human interpretable, low-cost, approximate
solution. Intelligent systems have demonstrated great performance to a
variety of areas including big data analytics, time series, biomedical and
health informatics etc.
This book covers the latest advances and developments in health infor-
matics, data mining, machine learning and artificial intelligence, fields
which to a great extent will play a vital role in improving human life. All
the researchers and practitioners will be highly benefited those are work-
ing in field of biomedical, health informatics, Big Data Analytics, IoT and
Machine Learning. This book would be a good collection of state-of-the-
art approaches for Big Data and Intelligent based biomedical and health
related applications. It will be very beneficial for the new researchers and
practitioners working in the field to quickly know the best performing
methods. They would be able to compare different approaches and can
carry forward their research in the most important area of research which
has direct impact on betterment of the human life and health. This book
would be very useful because there is no book in the market which pro-
vides a good collection of state-of-the-art methods of Big Data, machine
learning and IoT in Biomedical and Health Informatics. Various models
for biomedical and health informatics is recently emerged and very un-­
matured field of research in biomedical and healthcare. This book would
be very useful because there is no book in the market which provides a
good collection of state-of-the-art methods of for Big data analytics based
models for healthcare.

Organization of the Book

The 12 chapters of this book present scientific concepts, frameworks and
ideas on biomedical data analytics from the different biomedical domains.
The Editorial Advisory Board and expert reviewers have ensured the high
caliber of the chapters through careful refereeing of the submitted papers.
For the purpose of coherence, we have organized the chapters with respect
to similarity of topics addressed, ranging from issues pertaining to the
internet of things for biomedical engineering and health informatics, com-
putational intelligence for medical data processing and Internet of medical
things.
 Preface xv

In Chapter 1, “An Introduction to Big Data Analytics Techniques in

Healthcare”. Anil Audumbar Pise presents the use of big data analytics in
medicine and healthcare which is incredibly powerful, productive, inter-
esting, and diverse. It integrates heterogeneous data like medical records,
experimental, electronic health, and social data in order to explore the
relations among the different characteristics and traces of data points like
diagnoses and medication dosages, along with information such as public
chatter to derive conclusions about outcomes. More diverse data needs to
be combined into big data analysis, such as bio-sciences, sensor informat-
ics, medical informatics, bioinformatics, and health computational bio-
medicine to get the truth out of its information.
In Chapter 2, “Identify Determinants of Infant and Child Mortality
Based Using Machine Learning: Case Study on Ethiopia” Sudhir Kumar
Mohapatra, Srinivas Prasad, Getachew Mekuria Habtemariam, Mohammed
Siddique developed predictive models using four supervised machine
learning techniques namely C5.0 Decision tree, Random Forest, Support
Vector Machine and Naïve Bayes algorithms using the 2016 EDHS data-
set of 10,641 records. The Ethiopian government doing for the past two
decades for attaining millennium development goals agenda for prevent-
ing childhood mortality by improving the child health’s to change the
country image to the rest of the world in reduction of childhood mortal-
ity. This study contributes some values in the improvement of childhood
health by analyzing the determinants infant and child mortality by using
machine learning techniques. Different reports indicate that the distribu-
tion of childhood mortality differs in the world.
In Chapter 3, “Pre-Trained CNN Models in Early Alzheimer’s Prediction
Using Post-Processed MRI” Kalyani Gunda and Pradeepini Gera test MRI
Scan with Dementia or Not by Non-image MRI Evidence using Random
Forest Classifier which obtained 87% accuracy without false prediction and
also by predicting Alzheimer’s Progression using advanced CNN models.
Gentle Dementia is more focused to train the Early Detection by omitting
converted MRI Sessions. Various Transfer Learning Deep Neural Networks
like Residual Network (ResNet50), GoogleNet, VGG19 (Visual Geometric
Group), MobileNet, AlexNet is compared to classify Alzheimer’s. Model
comparison evaluated to explicate model efficacy.
In Chapter 4, “Robust Segmentation Algorithms for Retinal Blood
Vessels, Optic Disc, and Optic Cup of Retinal Images in Medical Imaging”
Birendra Biswal, Raveendra T., Dwiti Krishna Bebarta, Geetha Pavani P. and
P.K. Biswal discussed the several robust segmentation algorithms such as
a new statistical-­based Kurtosis test, a novel hybrid active contour method
with a new pre-processing technique is applied to fundus images of human
xvi Preface

eyes for observing the changes in Retinal Blood Vessels and Optic Disc &
Optic Cup to classify as healthy or diseased eyes.For validating all these
robust segmentation algorithms standard metrics are used in evaluating
the performance of segmentation models. Consequently, the experimen-
tal result and comparison analysis are presented to estimate the efficacy
of the proposed algorithm. As a result, standard metrics of the proposed
algorithm were compared with many other previous methods suggested by
various researchers and it is confirmed as to attain better efficacy values.
In Chapter 5, “Analysis of Healthcare Systems Using Computational
Approaches” Hemanta Kumar Bhuyan and Subhendu Kumar Pani high-
light recent contributions and efficiency of AI and ML in computer sys-
tems development for better healthcare and precision medicine. Despite
various traditional and AI-based solutions, current healthcare constraints
and challenges include uneven distribution of resources towards the future
of digital healthcare. Unmet clinical research and data analytics requires
the development of intelligent and secure systems to support the transfor-
mation of practices for the worldwide application of precision medicine.
Overarching goals include new multifunctional platforms that incorporate
heterogeneous clinical data from multiple platforms based on clinical, AI,
and technical premises. It must address possible challenges that continue
to slow the progress of this breakthrough approach.
In Chapter 6, “Expert Systems in Behavioral and Mental Healthcare:
Applications of AI in Decision-Making and Consultancy” Shrikaant
Kulkarni Present the latest technological advancements so as to showcase
futuristic challenges and a glance at potential innovations on the hori-
zon. The treatise enumerates the expert systems in behavioral and mental
healthcare areas. It also further discusses the benefits AI can offer to behav-
ioral and mental healthcare.
In Chapter 7, “A Mathematical-Based Epidemic Model to Prevent and
Control Outbreak of Corona Virus 2019 (COVID-19)” Shanmuk Srinivas
Amiripalli, Vishnu Vardhan Reddy Kollu, Ritika Prasad, Mukkamala
S.N.V. Jitendra provide a preliminary evolutionary graph theory based
mathematical model was designed for control and prevention of COVID-
19. In the proposed model, well known technique of social distancing with
different variations are implemented. Lockdown by many countries leads
to the decrease of Gross Domestic Product (GDP) and increase in mental
problems in citizens. These two problems can be solved by the administra-
tion of antivirus in some form to the public as a counterpart to the virus.
This model works more effectively with high percolation of antiviral nodes
in a population and over a period of time. There should be an exponential
growth of antivirus nodes to heal the infected population.
 Preface xvii

In Chapter 8, “An Access Authorization Mechanism for Electronic

Health Records of Blockchain to Sheathe Fragile Information” Sowjanya
Naidu K. and Srinivasa L. Chakravarthy focuses on maintaining the
patient records in the blockchain immutable ledger which allows the doc-
tors to upload the patient records and give access to other doctors and
also impose certain rights to the patients to revoke the access to everyone
which provides security to the patient’s records. This can also be extended
to the insurance providers where they use the immutable ledger of the
Electronic Health Records chain to check the patient’s records and pay-
ments. Block chain technology allows the patients to assign access rules
for their medical data. Block chain technology is expected to improve the
Electronic Health records management and the claim process by the insur-
ance agencies also. Not only does the Blockchain enhance the security of
the data but it also helps to reduce the long and tedious process of the
interhospital transfers and simplifies the process of record keeping of the
Electronic Health Records. This work is beneficial to many stakeholders
who are related to the medical system to carry better health services and
provide security to the user’s rights of protecting the data. An attempt has
been made to design a framework for the individuals to access the data on
the blockchain. The frameworks propose a layered approach for accessing
the data of the patient by different stakeholders.
In Chapter 9, “An Epidemic Graph’s Modeling Application to the
COVID-19 Outbreak” Hemanta Kumar Bhuyan and Subhendu Kumar
Pani present a novel machine learning approach that can estimate any
epidemiological model’s parameters based on two types of information:
either static or dynamic. It primarily utilizes the Graph model using deep
learning approaches and Long-term memories (LSTMs) to obtain mobility
data’s spatial and temporal properties of SIR and SIRD models. It runs and
simulates using data on the Italian COVID dynamics and compares the
model predictions to previously observed epidemics.
In Chapter 10, “Big Data and Data Mining in e-Health: Legal Issues and
Challenges” Amita Verma and Arpit Bansal focus on the legal framework
with respect to privacy in India and a comparison of the same with other
countries. E-Health is a rising industry. At a time when physical healthcare
facilities are full of COVID19 patients, the e-Health Industry has become
even more diverse and is being resorted to as primary healthcare system
specially to treat regular health problems.The health data of millions of
patients is being stored online. The same is done through the concept of
Big Data and Data Mining in e-Health. In India, National Digital Health
Mission is aimed towards the use of this technique to simplify e-Health
services.
xviii Preface

In Chapter 11, “Basic Scientific and Clinical Applications” Manna Sheela

Rani Chetty and Kiran Babu C. V. discuss the various applications and its
significant advancements in medicine and health care. Appling the princi-
ples of computer science and information science to the advancement of
research in the area of life sciences, health professions education, public
health, patient care, etc. can be considered as biomedical and health infor-
matics (HI). The integrative field and multidisciplinary focuses on health
information technologies, and involves the computer, cognitive, and social
sciences. Informatics is one of the sciences which reflects how to use data,
information and knowledge to improve human health and the delivery of
health care services. HI studies the effective use of probabilistic informa-
tion for decision making. The combination of both has greatest potential to
rise quality, efficacy and efficiency of treatment and care.
In Chapter 12, “Healthcare Branding Through Service Quality” Saraju
Prasad and Sunil Dhal offer a deep insight into the service quality model
dimensions in healthcare. In India the healthcare services can be divided
into two categories like public and private healthcare services. The Public
Healthcare System (PHC) which is under the control of government is
available in cities and rural areas and provides services mostly primary
services. Majority of the private sector healthcare service providers are in
metropolis, capital cities and few others cities of the country mostly focused
on secondary and tertiary services. India got the competitive advantages
in maximum number of experienced medical practitioners.

Concluding Remarks
The chapters of this book were written by eminent professors, researchers
and those involved in the industry from different countries. The chapters
were initially peer reviewed by the editorial board members, reviewers, and
those in the industry, who themselves span many countries. The chapters
are arranged to all have the basic introductory topics and advancements as
well as future research directions, which enable budding researchers and
engineers to pursue their work in this area.
Big Data Analytics and machine intelligence in biomedical and health
informatics is so diversified that it cannot be covered in a single book.
However, with the encouraging research contributed by the researchers
in this book, we (contributors), editorial board members, and reviewers
tried to sum up the latest research domains, developments in the data
analytics field, and applicable areas. First and foremost, we express our
heartfelt appreciation to all the authors. We thank them all for considering
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Exploring the Variety of Random
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 CHAPTER X
Very early in the morning, in the dark hour that precedes the
dawn, Marny Geradine rode out from Algiers in the guise of an Arab
boy, her slender figure concealed in the voluminous folds of a long
white burnous, her fair face hidden by the haick that was pulled far
forward over her brow. Beside her Hosein was riding with a wary eye
on her horse, ready at any moment to catch the bridle should the
nervous strength that was supporting her fail suddenly. A few paces
ahead of them, Carew, in the dark blue burnous he affected, was
hardly distinguishable in the gloom. Trembling with bodily weakness
and the still lingering fear she could not conquer, she strained her
eyes to keep him in sight. Only with him near her was she safe. On
him and on his strength she was utterly dependent, for she had no
longer any strength of her own. The courageous spirit that had
sustained her for so long was broken at last, and spent in mind and
body her only hope was in him. He had sworn that she was safe,
that he had passed unrecognised through the Villa des Ombres, that
he had brought her unseen to his own house. But the words that
had soothed her as he held her in his strong embrace seemed to
lose power when he was absent. He had been obliged to leave her
almost at once and the touch of his first kiss was still warm on her
lips when he had hurried away to make the arrangements for which
so little time was available. He had bade her rest, but nerve racked
and overwrought, rest had been impossible as she lay starting and
shivering at every noise that echoed through the strange house. Like
a terrified child that requires repeated and audible consolation, she
longed for the sound of his voice, for the tangible comfort of his
shielding arms.
And now as she rode through the deserted streets of the
sleeping suburb, fear for herself was mingled with a new and terrible
fear for him. She had as yet no knowledge of what had passed in
the Villa des Ombres after she had lost consciousness and she was
obsessed with the thought of her husband. She saw him in every
shadow, the very sound of the horses’ feet seemed to her excited
fancy like hurrying pursuing footsteps. She hated herself for her
want of confidence. At the bottom of her heart she knew that her
trust in Carew was implicit, that it was only her overstrained nerves
that made her shiver with dread, that turned her sick each time her
horse quickened his pace or swerved from some object that only he
could see. She tried to fight against her weakness, to believe that
her disguise was complete, but she knew that she would have no
peace until the town was left behind, until, the open country
reached, she could abandon the rôle of attendant and ride beside
the man to whom she had given herself and gain fresh strength and
courage from his nearness. And from time to time unconsciously she
strove to lessen the distance between them, checking her horse
again with a sharp little sigh as she heard Hosein’s voice
“Doucement, doucement” repeated warningly.
The way seemed never ending.
To avoid passing the Villa des Ombres a wide detour was
necessary and Marny began to think they would never win clear of
the tree-lined avenues and succession of silent villas that appeared
to extend indefinitely.
There were few abroad at this early hour, but the occasional
passing of some chance pedestrian made her shrink within the folds
of the enveloping burnous, wild eyed with apprehension and faint
with the heavy beating of her tired heart. And once the sound of
galloping hoofs behind them came near to shattering what little self-
control was left to her and with a choking cry she drove her horse
against Hosein’s, clutching frantically at the man’s arm and reeling
weakly in the saddle. But it was only an Arab, wraith-like in the
darkness and immersed in his own concerns, who tore by at
breakneck speed on a raking chestnut that squealed an angry
defiance at the other horses as he clattered past. She recovered
herself with a feeling of shame for her own cowardice, wondering
miserably if she would ever regain the strength and nerve that five
years of crushing experience had slowly sapped from her. Once she
had not known what it meant to be tired or afraid. Weariness and
pain to her had been merely terms, without meaning, without
significance. But in those five years she had learnt a bitter lesson.
Physically and mentally she had suffered until suffering had become
the dominant factor in her existence, until she had wondered how
far endurance went, how long before her burden would become
heavier than she could bear. And now, still dazed with the horror of
the last few hours, she could hardly believe in the fact of her
deliverance. Was it really over, the life of pain that had transformed
her from a happy carefree child into a sorrowful disillusioned woman
who had prayed for death to release her from bondage that was
intolerable. And death had been very near to her last night. She had
realised it when, seeking to prevent what she knew to be an
injustice, she had thrown herself between her husband and the
wretched Arab valet and Geradine, mad with drink and rage, had
turned to wreak on her the same punishment he had inflicted on his
servant. His face had been the face of a devil, distorted almost
beyond recognition, and in his glittering red flecked eyes she had
read her fate. Temporarily insane he was past knowing what he did
and, helpless against his strength, she was well aware now that but
for the coming of Carew the ghastly scene must have ended in
tragedy, that body or brain must have succumbed to the fury of his
passion. Never while she lived would she forget. Still close to hers
she seemed to see that savage bestial face, the staring bloodshot
eyes blazing with merciless ferocity, her lacerated shoulders still
quivered as if they shrank again under the cruel blows that had
rained on her till consciousness fled. The brutality of years had
reached culmination when, with words whose foulness had scorched
her soul, he had beaten her like a dog. That was what she had
been! His dog—kicked or caressed as the mood took him. A thing of
no account. His chattel—sold to him like a slave in an eastern
market, taken by him merely to satisfy his basest instincts.
Shudderingly she tried to banish thought, to put him from her mind,
but her shaken brain was beyond control and over and over again
she lived through the cruelty of the years that were past until every
nerve in her aching body seemed strained to breaking point.
 Trembling from head to foot and bathed in perspiration she
wondered if the horror of it would ever leave her, if all her remaining
life was to be a nightmare of hideous recollection.
Drooping with fatigue, her wet hands slipping on the bridle she
grasped mechanically, she prayed desperately for the open country
that meant freedom and happiness. And gradually, yielding to the
physical pain that was swamping all other feeling, she ceased to
notice the locality through which they were passing and she had
almost drifted into unconsciousness when the sound of the voice she
had longed for roused her to the fact that at last the town was left
behind. Slowly she raised her head to meet the grave eyes that
looked searchingly into hers. And at sight of her face Carew reined
nearer, and she felt his cool strong fingers close with practised touch
about her wrist.
“Can you hold out a bit longer, dear? We’re rather close to Algiers
yet,” he said. And the tender anxiety of his voice made her set her
teeth to keep back the sob that rose in her throat, a sob of joy and
wonder at the consideration to which she was so unused. She drew
herself straighter in the saddle and smiled at him bravely.
“I’m all right,” she gasped, “if—if I can ride beside you,” she
added, faintly. His lips tightened as he eyed her doubtfully. Then
without answering he wheeled Suliman towards the south.
The movements of her horse were easy, and away from the
metalled roads the slow canter at which they rode was less jarring,
but it took all her resolution to maintain the upright carriage she had
adopted and hide from him the weakness that was steadily
overcoming her. The nervous strength that had upheld her at first
was slipping from her fast now that the immediate fear of discovery
was past, and in the reaction of relief she feared the collapse that
was threatening momentarily. She pulled the haick closer about her
face that he might not see the moisture lying thick on her forehead
and rode on with compressed lips fighting the spells of faintness that
made her head reel and the surrounding landscape appear to waver
in curious undulations before her eyes.
The dawn was brightening. Already it was light enough to see
distinctly, and despite her fatigue, Marny looked with interest on a
district that was new to her.
For some time still their way led past farms and fruit gardens, but
of human life they saw little. And the few field workers and
goatherds they met were absorbed in their own affairs and paid no
heed to their passing, or at most bestowed on them a perfunctory
salaam that was due to Carew’s supposed rank. He looked like a
chief, she thought with a strange new feeling of pride. It was difficult
seeing him thus to remember that he was an Englishman. To her he
would always be an Arab, a man of the open, a desert dweller. And
in the sandy wastes of the great wilderness towards which her
thoughts had turned so longingly she would live with him the wild
free life of her dreams, a life that might prove hard and dangerous
but a life that would be made sweet by his love and companionship.
If only she need not have come to him like this! If only he had found
her in the time of her unfettered girlhood when he could have taken
her unstained and without dishonour! But over their love now hung
the shadow of disgrace. And it was for her sake that he had done
what would be held up to him as a reproach. For her sake—He
heard the strangled sob she tried to smother and winced, his eyes
sweeping the horizon impatiently. He knew that she had almost
reached the limit of her endurance and his arms were aching to hold
her, to ease the pain of her weary little body against his own strong
limbs, but while the scattered farms still stretched about them he
dared not risk the chance of passing observation. Neither, because of
her weakness, did he dare to quicken their slow pace—an
unaccustomed pace at which Suliman was fretting and protesting,
rearing from time to time as he tried to break into the usual gallop.
But at length the last outlying vineyard was passed, and
screened by the rising ground of the foothills they were approaching,
precaution was no longer necessary. With a sigh of relief Carew
swung his horse close to hers and, bending sideways, lifted her
easily out of the saddle. She yielded without demur, relaxing against
him with a moan of utter exhaustion. He knew that she was crying,
but he knew also that the tears which hurt him so poignantly were
necessary to relieve the excited brain that had gone so perilously
near to destruction and he made no attempt to check them.
Tightening his arm about her he gave Suliman his head. And with a
snort of pleasure the big bay leaped forward, free to go his own
pace at last, galloping as he had galloped when once before he had
carried double. The memory of that midnight ride came to Carew as
he glanced down at the girl he held before him. With what different
feelings he had carried her then! How he had revolted at her
proximity, hating the slight burden that was now so precious. Every
moment had been torture. Now, in the ecstasy that filled him, he
wished that the way were longer, that the moment might never
come when he would have to waken from his dream ride of almost
unbelievable happiness and face the stern realities of the difficult
course that lay before them. For an instant his sombre eyes grew
stern and brooding, then he thrust the thought of the future from
him. There was time, and enough to think of that. Now he could
only think of her. His face grew very tender, very pitiful as he looked
at her. Poor little tired child, bruised and broken with appalling
experience—would even his love, great as it was, compensate for
the suffering that had wrecked her young life? All that was best in
him rose up as he caught her closer with a stifled whisper. That he
might never fail her, that she might never regret the step she had
taken, never regret the faith she had in him, was the prayer that
burst from his innermost soul—a prayer that was deeper, more
fervent than any he had ever uttered in his life.
But as the bay tore on with long swinging strides that were the
perfection of movement, Carew put from him everything but the joy
of the moment. After the enforced stay in a town he had come to
loathe, after the tedious days of comparative inactivity made hideous
by mental struggle, he felt like a man released from prison. Behind
him lay all he wished to forget. Before him lay a new life, new
happiness, new hope. He could hardly realise yet what it meant to
him. No longer alone, with something more than his work to live for,
he seemed to see the world suddenly with new eyes—a world of
new wonder, a world transformed and beautified. Eagerly he looked
at the brightening sky. The dawn had almost come, a dawn that was
to him symbolical.
 A feeling of exultation came over him. The wild rush through the
air, the cool wind blowing against his face, was like an intoxicant
stirring him as it always stirred him, and today more powerfully than
ever before. For did he not hold in his arms his heart’s desire—was
not the woman he had craved his at last! With a quick fierce laugh
he drove his knees into Suliman’s ribs and swung him round to face
the open hillside. Gallantly the horse attacked the steep incline, but
the gradient was punishing and gradually his pace slackened till it
dropped to a walk and, picking his steps carefully amongst the scrub
and boulders, he wound his way laboriously up the twisting track till
he reached the summit to stand with heaving sides and wide
distended nostrils.
And at the same moment the sun rose clear of the banking
clouds of gold and crimson, and the full light came with startling
suddenness revealing all the wild beauty of the desolate hills. A
scene of more than ordinary grandeur, or so it seemed to the man
whose heart was throbbing with a passion that almost frightened
him and whose whole sensitive being was thrilling and responding to
the radiant glory of this most marvellous sunrise he had ever
witnessed. Behind them Hosein was on his knees absorbed in rapt
devotion, and alone with her he viewed the advent of the new day,
the new life that they would live together. The reins dropped loose
on Suliman’s neck as he raised her high in his arms till their lips met
and her shy eyes fell under the ardour of his burning kiss. A kiss that
with its hungry passion, its complete possessiveness awoke her to a
fuller realisation of the step she had taken.
She was trembling when at last he released her, her quivering
face scarlet with shame. Miserably she stared at him, struggling to
free herself.
“Let me go,” she moaned. “I hadn’t any right to ask you—I
hadn’t any right to make it difficult for you.” But in her piteous eyes
he read the despair that gave the lie to her stumbling sobbing
words.
“You want to go—back to him?” he said, slowly. And he was
answered in the sharp cry that burst from her as she shuddered
closer into his arms, clinging to him with all her feeble strength. With
a soft little laugh of triumph he kissed her again and turned in the
saddle to shout to Hosein who had finished his prayers and was
waiting discreetly in the background with no sign of his inward
astonishment visible in his imperturbable face. That the master he
worshipped had been stricken with sudden madness was to him the
only possible explanation for the departure from established
principle, that in his years of service he had become thoroughly
acquainted with. Shrewdly observant he had seen and wondered at
the gradual change that had come over Carew since the night when
he had amazed his retainers by bringing a woman to the camp from
which women had always been religiously excluded. And now that
same woman was lying across his saddle, a willing captive to the
man who was bending over her with a face that was transfigured.
That his master had no right to her, that she was the wife of the
foreign Sidi who had made himself so notorious in Algiers, were
matters of indifference to Hosein. It was no business of his. If his
lord had at last found happiness—who was he to judge him! He had
been mad with that same madness himself once—
As he ranged alongside leading the spare horse, Marny tried to
raise herself.
“I’m rested now—let me ride,” she murmured. But Carew saw her
face contract with the pain that movement caused her, and shook his
head. “You are not fit to ride. Lie still and rest,” he said, decisively.
“But you can’t carry me all the way, I’m so heavy—” she
objected, faintly.
“Heavy!” he laughed, “about as heavy as an extra carbine.”
And following his swift glance she noticed for the first time the
leathern holster that projected beyond his knee. The sight of it
reminded her of the hazardous life that would be hers and made her
rebel against the weakness that seemed to make her so unfit a
companion for him.
“Let me try,” she pleaded. But he shook his head again.
“Do as you’re told my dear,” he said, with a smile that softened
the peremptoriness of his tone. “You’re worn out, and you are on the
highroad to fever unless you take things easily. I can’t have you
knocking up out in the desert. You’ll want all your strength where
we’re going.”
Where were they going? She wondered without caring. She knew
nothing of his plans. She was content to go where he took her,
content to follow where he led. She had given her life into his
keeping, she was satisfied to leave to him the ordering of that life.
With a tired sigh she dropped her head on his breast, thankful for
the support of the strong arm crooked about her, yielding to the
strength that was so strangely gentle.
A drowsiness she did not attempt to combat stole over her as she
lay with closed eyes listening to the murmur of the two men’s voices.
They were speaking in Arabic which she did not understand, but it
seemed to her that Carew was giving certain orders to which his
servant responded with his usual brevity. Then there was silence and
dreamily she became aware that Hosein had left them and that they
were alone on the top of the sun warmed hill. Dead with sleep she
felt Carew’s arm tighten round her, heard without fully
comprehending his explanation that he had sent the Arab on to
prepare the camp for their coming, and slept as his lips touched
hers.

It was late in the afternoon when she woke. Still heavy and
confused with sleep, at first she was conscious only of the feeling of
bodily comfort that enveloped her. Her tired limbs were at rest and
she lay propped against soft cushions that eased the dull ache of her
wounded shoulders. With a little sigh of physical content, she
nestled deeper into the silken pillows, inhaling the faint oriental
perfume that clung about them, wondering vaguely when Ann would
come to waken her. Ann? Ann would never come to her again! Ann
was gone, the victim of petty spite and tyranny. And she—With a
strangled cry she started up, trembling violently, staring around her
in bewilderment. Then remembrance came with a rush, and sobbing
with relief she sank back on the cushions of the wide divan where
once before she had slept with such curious confidence.
Wonderingly she looked about the room, at the simple but costly
Arab furnishings, at the well stocked gun rack that stood near the
couch on which she was lying, at the litter of masculine belongings
that with their suggestion of intimacy served to bring home to her
even more fully than before the significance of what she had done.
His room! The hot blood flamed into her cheeks and she hid her face
in the pillows, whispering his name, shivering with a new sweet fear
and joy that made her long for him and yet shrink from even the
thought of his coming.
How long since he had brought her here? How long since she
had fallen asleep in his arms on the top of the sun-bathed hill? The
room was perceptibly darker when at last she raised her head and
sat up, listening for some sound to penetrate from the adjoining
room that should assure her of his nearness. But she heard only the
distant hum of the scattered camp—the shrill squeal of an angry
stallion, the doleful long-drawn bray of a donkey and, near at hand,
the monotonous creak and whine of some unknown piece of
mechanism whose use she could not guess. Strange, unfamiliar
noises that yet seemed so oddly familiar, like the faint echoes of a
far-off memory urging the remembrance of another long forgotten
life when she had lived and loved in close proximity to the sounds
that now thrilled her with vague wonderings. Did love ever die—was
this passion that had overwhelmed her so suddenly only the
reawakening of a love that had been born in bygone ages? Had she
loved him then! Had he too lived in that remote past that seemed
struggling for recognition? Had their wandering souls, long desolate
and alone triumphed over the barrier that separated them to
converge once more and know again the transient rapture of earthly
happiness?
With a tremulous smile she slipped from the couch and went
slowly to the little dressing table at the further end of the room.
Curiously she stared at herself in the tiny mirror, frowning at the
weary white face she saw reflected.
The close-drawn haick had been removed and, tumbled by the
heavy head-dress, her hair lay loose in curling waves about her
shoulders. The colour crept into her cheeks again as she strove to
roll it up into something approaching order. And as she wrestled with
the few pins that remained to her, two hands placed suddenly on her
shoulders made her start violently. “Must you hide it all away? It was
very pretty as it was.” There was a new note in his voice, a new hint
of definite ownership in his manner as he coolly unloosened the soft
coils she had hastily bound up and drew her to him. But she dared
not meet his look and, surrendering to his arms, she hid her face
against him in an agony of shyness.
With a tender word of expostulation he slipped his hand under
her chin and raised her head. His ardent love was crying out for
expression but the shamed piteousness of her eyes checked the
passionate words that rushed to his lips. What was his love worth if
self came before consideration? He stooped his cheek to hers.
“Do you think I don’t understand,” he murmured, “do you think I
don’t realise how—strange it is? But you can’t be shy with me, dear.
Only remember that I love you, that I’d give my life to keep you
happy. I’ll do all I can to make it easy for you—” But even as he
spoke the restraint he imposed on himself slipped for a moment and
he crushed her to him conclusively. “Child, child, if you knew how I
have longed for you! If you knew what it means to me to hold you in
my arms—here—to know that you are mine, mine, utterly. Marny—”
He pulled himself up sharply with a gesture of compunction, his
hands dropping to his sides.
“Forgive me, dear,” he said, gently, “I didn’t mean to be rough
with you—I wouldn’t hurt you for the world.”
The tears that were so near the surface welled into her eyes and
she looked at him strangely.
“Rough?” she whispered, slowly. “I wonder if you know what
roughness means—I wonder if you could hurt me if you tried!” Then
her face contracted suddenly and her hands went out to him in
shuddering appeal. “Keep me from remembering!” she cried, wildly,
“help me to blot out the past. I can’t tell even you. I want to forget
—everything—everything but your love. Oh, my Desert Healer, you
heal others, heal me too! Make me strong again—strong and fit to
share your life, to be your helper—Don’t let me think! Oh, Gervas,
don’t—let—me—think!”
The look he had dreaded to see again was back in her eyes and
her whole body was shaking as she clung to him with all her shyness
forgotten in the greater mental distress that made her seek his help
and consolation. With almost womanly tenderness he soothed her,
holding her till the nervous trembling passed and she lay still in his
arms.
“It’s over,” he said, at last, “over and done with. It’s a new life
we’ve begun together, dearest. A new life that will bring you health
and strength and, God helping me, a greater joy than we have ever
known. The desert will heal you, Marny, as it healed me years ago.
Shut your mind to the past. Think only of the future—and of our
happiness.”
A bitter sob escaped her.
“We haven’t any right to be happy,” she moaned. He did not
answer but she felt him stiffen suddenly and her eyes leaped to his
with a new fear dawning in them.
“Gervas—” she gasped, “what will you do—if he won’t divorce
me? Oh, you don’t know him as I do, you don’t know of what he is
capable. He would do it just to feel that his power was over me still,
just to keep me bound, just to hurt us. Gervas, if I can never be
free, if I can never be your wife—what then?”
A shadow passed over his face as he looked down at her.
“Will the price of our happiness be too big for you to pay, Marny
—or is it me that you doubt?” he asked, slowly.
“Gervas—” But his kisses stopped her frantic protestations and
there was only love and pity in his eyes as he gathered her closer.
“You will always be my wife—as you are my wife to me, now.
Nothing can ever alter that. Nothing shall ever come between us.
God knows how you’ve suffered, and He can judge me for what I
have done when the time comes. But while I live you’re mine and no
power on earth shall take you from me.” His deep voice was vibrant
with passion and for a moment the fierce pressure of his arms was
pain. Then as if ashamed of his own display of feeling he put her
from him.
“I’m a brute,” he exclaimed, remorsefully. “Come and eat, you
pale child. I hadn’t the heart to wake you before, you were sleeping
so soundly.”
 Shyness fell on her again as he led her into the adjoining room.
And throughout the meal that followed she was very silent, eating
mechanically what was put before her and studiously avoiding his
eyes as from time to time she glanced with furtive curiosity about
the big tent.
His heart ached for her as he watched her with an intentness he
was careful to conceal. He was longing to help her, longing to make
easier the difficult situation which he knew she was only now
realising in its entirety, fearful of augmenting her constraint by any
word or gesture that should emphasise the new relationship
between them. Love made it easy for him to guess her thoughts.
With fine intuition he understood perfectly the struggle that
complete realisation must have awakened in her mind. Though she
loved him, though she had given herself to him, still he knew that
she must be shrinking sensitively from the consequences of her own
act. His arms had been a refuge she had turned to in her need, but
they were the arms of the man who loved her and here, in his tent,
she must be facing the hard fact of her obligation, facing the
payment of her freedom—a payment that only love could make
endurable. More than ever did his own love clamour for utterance
but he gripped himself resolutely, playing the part of impassive host
with almost cold courtesy while he attended to her wants and
keeping the conversation strictly to trivialities, and trivial
conversation was not easy. They knew so little the one of the other.
He had as yet no knowledge of her tastes, no knowledge of her
interests. In spite of the love that had swept them both off their feet
they were, to all intents and purposes, strangers to each other, and
further hindered by her shy reserve a common meeting ground was
difficult to find.
But when the short twilight had faded and the lamps were lit in
the tent, when Hosein had come and gone for the last time leaving
them alone, he found it impossible to maintain the detached attitude
he had adopted, impossible to avoid reference to certain subjects
that must of necessity be discussed between them. The sense of
their aloneness, the intimacy of the moment, was stirring him deeply
and the sight of her lying amongst the heaped up cushions of the
divan, lovelier than he had ever seen her, infinitely pathetic as she
seemed in her utter dependence on him, was an appeal that was too
strong to be resisted and his heart was beating furiously as he went
to her.
And affected no less than he, her breath came fast and her shy
eyes met his for only a moment as she moved to make place for
him. Sitting down beside her he caught her slim hands up to his lips.
Then, still holding them in his firm grasp, he crashed through the
faint barrier that had risen between them and spoke with unreserved
frankness of the future and the life that they would share together.
And afterwards, because he believed that only by mutual confidence
and trust could their love be perfected, he broke the silence of years
and told her the story of his life, the tragedy that had wrecked his
early manhood and driven him to a self-imposed exile, and of the
consolation he had found in the work that had become so dear to
him. And his own confidence ended, he drew from her, bit by bit, the
history of her girlhood and pitiful marriage. But of what she had
suffered at the hands of the brute to whom her brother had sold her
she would say nothing.
“You know,” she whispered, with quivering lips, “you saw—the
morning after the Governor’s ball. I can’t speak of it. It hurts me.”
For a moment he held her closely, his eyes blazing as once before
she had seen them blaze, then he rose abruptly and striding across
the room flung back the closed entrance flap and stood in the open
doorway staring out into the night.
She twisted on the divan to watch him, wondering what chain of
thought her words had set in motion, wondering if he was vexed at
her reticence. But he gave no explanation of his hasty movement,
and after a time he came back slowly, his face inscrutable as she
had ever known it, and squatted, Arab fashion, on a pile of cushions
near her. Lighting a cigarette, for a while he talked fitfully, his brief
remarks punctuated by lengthy silences she did not know how to
break. And as the evening wore on he grew more and more distrait
until finally he ceased to speak at all, sitting motionless with his eyes
fixed on the rug, smoking cigarette after cigarette.
 She knew that it was late. The tom-toms and pipes, that earlier
in the evening had resounded from the men’s quarters, had long
since died away. She was conscious of a silence that could be almost
felt, she found herself straining her ears to catch some sound that
should moderate the deep quiet that was reminiscent of long ago
nights in Ireland. But for once there was peace amongst the
picketed horses and not even the wail of a jackal came to break the
intense stillness. It was as if all the world slept and only she was
awake—she and the man to whom she must soon yield the final
proof of her love and surrender. She slid her arm across her burning
face and shrank closer against the silken pillows, shivering
uncontrollably, torn with the conflict that raged within her. She loved
him, with her whole being she loved him—madly, utterly. To give him
all he demanded would be joy beyond expression—but, oh, dear
God, why must their love be stained with sin! Last night he had
loved her well enough to let her go—and her coward body had
driven her to plead with him until his renunciation became
impossible. It was she who was responsible. It was her sin, not his—
and let her be the only one to pay. Passionately she prayed it,
clenching her teeth to smother the sounds of agony that rose in her
throat. Weak with emotion, vaguely frightened by his continued
abstraction, she was aching for the clasp of his arms, hungering for
his kisses, longing for the comfort and reassurance of his voice. Of
what was he thinking as he sat motionless, scowling heavily as he
stared into space, no longer even smoking. Was it the remembrance
of the early sorrow of which he had told her that made his face so
stern and sad? A swift spasm of jealousy shook her. But she crushed
it down, her tender brooding eyes growing misty with tears. What
need had she to be jealous! The past was over—and his love was
hers. He had proved it beyond all doubt. And he had done so much
already, it was foolish to expect that every moment of his time could
be given to her. He had other matters beside herself to engage his
attention, matters that now, because of her, must necessarily have
become more complex. It was only natural that he should be pre-
occupied and silent. She must be content to wait. He would turn to
her again in his own good time.
 And when at last he stirred and rose with swift noiselessness to
his feet, she was lying so still that he thought she was asleep. For a
moment he bent over her, his hands reaching out to the little
recumbent body, his strong limbs shaking with the fierce tide of
emotion that was pouring over him, his passionate eyes aflame with
love and longing. Hungrily he gazed at the woman he had taken for
his own. Why did he hesitate? Was she not his, his of her own free
will, his to give him all he asked! Of what use to refrain? Who, after
what he had done, would believe that he had spared her! And if her
fears were justified, if she failed to win release—what would either
of them have gained? If not tonight—then sooner or later, for he
would never let her go. Wife or mistress, whichever it was to be, he
would keep her while the breath of life was in him. Lower and lower
he bent till the warm sweet nearness of her, the faint intoxicating
perfume of her fragrant hair, and his own desperate need combining
shattered the last remnant of his self-control and he swept her up
into his arms, straining her to his heaving chest, raining kisses on
her lips, her eyes, her palpitating throat, till, panting and exhausted
with the force of his ardent embrace, her head fell back against his
shoulder and he carried her white-lipped and trembling towards the
inner room. But as he reached the screening curtains that barred his
impetuous way he came to a sudden halt and the quivering
eagerness of his face gave way to a look of doubt and bitter misery.
Yearningly he stared into her frightened eyes, then with a gasping
sob he slid her slowly to her feet and pushed her gently through the
silken hangings. “Go—for God’s sake go,” he muttered, and
wrenched the curtain into place.
Not yet! Not while there still remained a chance that he might
take her without dishonour. What the world would not believe was
yet possible to him who loved her. Until he was sure, beyond all
doubt, that she could never be legally free to marry him he would
hold her unscathed, unsoiled by his passion. And, Merciful God, how
long would that be? How long would he be able to hold out! He was
pledged to Sanois and he had sworn to take her with him. Was he
strong enough to withstand the temptation of long months spent in
close proximity, riding day after day at her side under the burning
sun, sleeping night after night with only a frail curtain between
them? He did not know. He only knew that tonight his strength was
gone and that he dared not stay beside her. The calm radiance of
the star-lit sky, the deep stillness of the night mocked his as he fled
from the tent he did not trust himself to look back on. A night of
mystical beauty, redolent with the subtle odours of the east,
languorous and heavy scented—a night for love and the fulfillment
of desire.
With a groan he swept his hand across his eyes, wrestling with
physical agony that was intolerable, cursing the scruple that kept
him from her, cursing the man who stood between them. The blood
was beating in his ears and his brain was on fire as he stumbled
through the shadowy darkness of the little valley, striving to subdue
the longing that possessed him, striving to banish the torturing
thought of her nearness. Blind to the road he was taking, he saw
only the sweet pale face that had flushed to the touch of his burning
kisses, saw only the tempting beauty of the slender loveliness he
craved. Was she asleep, as he prayed with all his soul she might be
—or was she too awake, longing for him as he was longing for her,
suffering as he was suffering? Just now she had trembled in his
arms and he had seen the fear that leaped to her flickering eyes, but
she had made no effort to repulse him, had made no plea for
release. Instead she had clung to him. And it seemed to him that he
could still feel the touch of her fingers, ice-cold and shaking against
his, still feel the rapid beating of her heart, the tumultuous rise and
fall of her delicate bosom as he carried her swiftly across the room.
She had been willing, and he—He flung out his hands with a bitter
cry and dropped like a log, burying his head in his arms.
Hour after hour he lay motionless on the soft warm sand, too
passion swept to sleep, till at last the raging fever that consumed
him abated, and he knew that, for the time being, his victory over
himself was complete.
But there was no peace in his mind. There was another decision
that had to be made before the stars faded and the sun rose on a
new day—a decision he knew in his heart was already determined.
By acceding to the frenzied appeal of the woman he loved, in his
endeavour to save her from further suffering, he had done a thing
unpardonable. That did not trouble him. He did not regret it, he
would never regret it. Her happiness was the only thing that
weighed with him. Last night her need, and only her need, had been
his sole consideration. Mad with fear she had implored him to take
her from Algiers and, trembling for her reason, he had consented.
But tonight his thoughts were centered on the husband from whom
he had taken her. He would never give her up—but he would steal
no man’s wife in secret. He was going back to Algiers—going back to
face the man he had wronged. And what would be the outcome of
that interview? No matter what Geradine had done—she was his
wife. No matter what she had suffered at his hands—he was her
husband. No extenuating circumstances could gloss over the hard
indisputable fact or lessen his own culpableness.
What would Geradine do?
Carew rose deliberately to his feet with a harsh mirthless laugh.
He knew what he would do himself if the position were reversed,
what he would unhesitatingly have done twelve years ago if the
opportunity had been given him. And if Geradine shot him like a dog,
as he deserved to be shot, what would become of the girl who
trusted to him? To stay—and forfeit his own self-respect. To go—
knowing that he might never return. Heavens above, what a choice!
But there was no other way thinkable. His mind was fixed, and the
rest lay with Geradine. Would the cur who had stooped to strike a
woman fight to regain possession of her, fight to avenge his honour?
If he only would—by God, if he only would! The breath hissed
through Carew’s set teeth and his strong hands clenched in fierce
anticipation as his mind leaped forward to the coming meeting. The
primitive man in him was uppermost as he thought with curious
pleasure of Geradine’s huge proportions and powerful limbs. There
was not much to choose between them. True he had thrashed him
last night, but the man had been drunk. Heaven send that he was
sober this time!
With a strange smile he swung on his heel and strode back to the
sleeping camp.
 But as he neared the tent his swift pace lessened and his sombre
eyes were dull with pain as he passed under the lance-propped
awning into the empty living room. How could he leave her to wait
alone until he came again—or did not come! What would be the
effect of those long-drawn hours of suspense on the nervous brain
that was already dangerously overstrained and excited? His stern lips
quivered as he parted the curtains and felt his way to the long low
couch that was only dimly visible.
His tentative whisper was answered by a stifled sob, and out of
the darkness two soft bare arms came tremblingly to close about his
neck and drew his head down to the pillow that was wet with her
tears. That she had wept bitterly was evident, and shaken by the
distress his resolution almost failed. But he crushed the momentary
weakness that came over him. “My dear, my dear,” he murmured,
huskily, “have I made you weep so soon? Have I failed you tonight
of all nights when you needed me most? Did you think I didn’t care
—that I didn’t want you! Do you think it was easy for me to go from
the heaven of your arms to a hell of loneliness under those cursed
stars? God knows it was hard—as hard as it is for me to say what
I’ve got to say to you now.” And with characteristic directness he
told her plainly the course he had decided.
At first she did not seem to understand, then as she grasped the
meaning of his words a cry of terror burst from her. “You can’t go—
you can’t, you can’t. Oh, Gervas, stay with me, don’t leave me! If
you go you’ll never come back and I—” she shuddered, horribly, and
her frenzied voice sank to an agonised whisper. “He’ll kill you.
Gervas, he’ll kill you!”
“Pray God, I don’t kill him,” he retorted, grimly, and with gentle
force he unloosened the tightly clasped arms that were locked about
his neck. “I’ve got to go, dear,” he said, steadily, “it’s the only thing I
can do.” And unable to bear the sound of her passionate weeping he
turned away. But with a wail of anguish she leaped to her feet,
striving with all her strength to hold him.
“Gervas, Gervas, don’t leave me like that—tell me you love me,
tell me you’ll come back to me—”
 For a long moment his lips clung to hers, then he laid her on the
bed. “You know I love you, Marny,” he answered, “it is because I
love you that I am going back to Algiers.” There was a note of
intense sadness in his voice that made her bury her face in the
pillow to stifle the sobs that were fast growing beyond control, but
there was also in it a ring of finality that made further pleading
impossible. Nothing she could say would move him. His will was
stronger than hers and she knew that, despite the love and
consideration that henceforward would make possession so different,
she had but exchanged one master for another.
When she raised her head again she was alone and she started
up, trembling with dread, listening till her ears ached that she might
hear the last sound of his voice. But there was only silence in the
adjoining room and, driven by an irresistible impulse, she fled
through the communicating curtains. The loose entrance flap was
only partially closed and, screened by the looped-back draperies she
waited scarcely breathing, straining her eyes through the gloom,
praying that she might see him once more.
And when he came it was only a momentary glimpse, a fleeting
impression of two shadowy horsemen who flashed past the tent to
vanish in the darkness beyond as though they had never been, and
sobbingly she stumbled back to the inner room, flinging herself in a
passion of tears on the bed where she had wept throughout the
lonely hours of the night. She did not question his action, it was
enough for her that he had done what he thought best. And there
was no bitterness in her grief. Selfless, she did not think of herself. It
was only of him she was thinking, only for him she was agonising.
The brutal strength she knew by terrible experience, the savage
unbridled nature she had learned so thoroughly—what would he do?
What ghastly tragedy would ensue from the meeting of these two
men so strangely opposite, so strangely linked by a common desire?
Tortured by horrible imaginings, mad with fear, she writhed in
mental anguish that took from her all power of reasoning, and
tossing to and fro on the soft bed that still gave no rest to her
aching limbs, she wept until she had no more tears, until exhausted
she fell asleep.
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