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Particle Therapy Technology
for Safe Treatment
Particle Therapy Technology
for Safe Treatment
Jay Flanz
Cover Art: Heaven’s Charged Particle Scanning System
First Edition published 2022

by CRC Press
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and by CRC Press

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ISBN: 978-0-367-64014-9 (hbk)

ISBN: 978-0-367-64311-9 (pbk)
ISBN: 978-1-003-12388-0 (ebk)
DOI: 10.1201/9781003123880
Typeset in Times LT Std

by KnowledgeWorks Global Ltd.
BK-TandF-FLANZ_9780367640149-211314-FM.indd 4 13/12/21 12:34 PM

Dedicated to Nancy, Adam and Scott
Thank you for your patience while putting up with it all.
Fun with Family helps to keep Physics Fun!
Cover Art: Heaven’s Charged Particle Scanning System

Contents
Chapter 1 Introduction................................................................................................................... 1
Chapter 2 Evolution of Medical Particles......................................................................................3
Chapter 3 A Personal Historical Perspective............................................................................... 13
Chapter 4 Flow of Requirements................................................................................................. 17

4.1 Direct Requirements......................................................................................... 17
4.2 Developmental Requirements........................................................................... 19
Chapter 5 External Beam Systems.............................................................................................. 21
Chapter 6 How to Damage Unwanted Cells................................................................................25

6.1 Direct Effects....................................................................................................26
6.2 Indirect Effects.................................................................................................26
Chapter 7 Exponentials................................................................................................................ 29
7.1 e........................................................................................................................ 29
7.2 Distributions..................................................................................................... 30
7.2.1 Binomial Distribution........................................................................ 30
7.2.2 Poisson Distribution.......................................................................... 31
7.2.3 Gaussian Distribution........................................................................34
7.2.3.1 Mean............................................................................... 39
7.2.3.2 Standard Deviation......................................................... 39
7.2.3.3 Skewness and Kurtosis................................................... 39
7.2.3.4 Gaussian Algebra........................................................... 39
7.2.3.5 Summation of Gaussians................................................40
7.3 Interactions....................................................................................................... 41
7.3.1 Can Hit the Broad Side of a Barn...................................................... 41
7.3.2 Interaction Target.............................................................................. 42
7.3.3 Target Hits......................................................................................... 43
7.3.4 Why Radiotherapy Works Mathematically....................................... 45
7.3.4.1 Tolerances...................................................................... 48
7.3.5 Attenuation........................................................................................ 49
7.4 Exercises........................................................................................................... 53
Chapter 8 Relativistic Dynamics................................................................................................. 55

8.1 Special Relativity (Briefly in this Time Frame)............................................... 55
8.2 Dynamics.......................................................................................................... 57
8.3 Exercises...........................................................................................................60
vii
viii Contents
Chapter 9 Charged Particle Interactions in Matter...................................................................... 61

9.1 Energy Loss...................................................................................................... 61
9.2 Ionization Potential...........................................................................................66
9.3 Linear Thickness or Mass Thickness............................................................... 68
9.4 Range................................................................................................................ 69
9.4.1 Range Sensitivity............................................................................... 72
9.4.2 Energy Loss, Distal Dose Falloff or Range Spread.......................... 73
9.5 Scattering.......................................................................................................... 74
9.6 Dependence of the Bragg Peak on the Beam Size........................................... 78
9.7 Energy Loss and Scattering Dependencies...................................................... 79
9.8 What Could Go Wrong – 1?.............................................................................80
9.9 Exercises........................................................................................................... 81
Chapter 10 Review of Charged Particle Motion............................................................................ 83

10.1 Manipulation of Light Rays.............................................................................. 83
10.2 Electromagnetic Forces....................................................................................84
10.3 Equations of Motion......................................................................................... 86
10.3.1 Bending in a Magnetic Field............................................................. 86
10.3.2 The Form of the Force....................................................................... 88
10.3.3 The Equations of Motion in a Magnetic Field.................................. 89
10.4 Effects of Beam Transport Elements................................................................92
10.4.1 Drift Space........................................................................................ 93
10.4.2 Thin Lens Focusing Elements........................................................... 93
10.5 General Ray Coordinate Transformation......................................................... 95
10.6 Optical Matrix Examples.................................................................................96
10.6.1 Momentum........................................................................................96
10.6.2 Longitudinal Position........................................................................97
10.6.3 Transverse Focusing.......................................................................... 98
10.6.3.1 Point-to-Point Focusing.................................................. 98
10.6.3.2 Point-to-Parallel Focusing..............................................99
10.6.3.3 Parallel-to-Point Focusing............................................ 100
10.6.3.4 Achromatic Combined System.................................... 101
10.6.4 Variables and Conditions................................................................ 102
10.7 The Orthogonal Direction.............................................................................. 102
10.8 Dipole Focusing.............................................................................................. 103
10.8.1 Sector Focusing............................................................................... 103
10.8.2 Pole Edge Focusing......................................................................... 104
10.9 Misalignments................................................................................................ 105
10.10 What Could Go Wrong – 2?........................................................................... 106
10.11 A Beam; A Gaussian Beam............................................................................ 107
10.11.1 The Ellipse...................................................................................... 108
10.11.2 Phase Space Representation and Equation of the Beam................. 109
10.12 Propagation of the Beam................................................................................ 111
10.12.1 Propagation of a Beam in a Drift Length........................................ 112
10.12.2 Representation of Apertures............................................................ 113
10.12.3 Dispersion........................................................................................ 116
10.12.4 The Effect of Multiple Scattering................................................... 117
10.13 Beam Matching Beamlines............................................................................ 117
10.15 Exercises......................................................................................................... 118
Contents ix
Chapter 11 Clinical Perspective of Charged Particle Therapy Beams........................................ 121

11.1 Longitudinal Direction................................................................................... 123
11.1.1 Beam Range.................................................................................... 123
11.1.2 Distal Penumbra.............................................................................. 125
11.2 Transverse Direction...................................................................................... 126
11.2.1 Field Size......................................................................................... 126
11.2.2 Lateral Penumbra............................................................................ 127
11.3 Dose Conformance......................................................................................... 127
11.3.1 Dose and Dose Rate........................................................................ 128
11.3.1.1 Dose............................................................................. 129
11.3.1.2 Counting Dose (Ionization Chamber).......................... 132
11.3.1.3 Dose Quantities, Dose Rate and Irradiation Time..........135
11.3.1.4 Maximum Count Rate.................................................. 138
11.3.1.5 Dose Rate Considerations............................................ 138
11.3.2 Some Particle Beam Treatment-Related Considerations................ 139
11.3.3 Beam Directions.............................................................................. 140
11.3.4 Additional Perspective.................................................................... 141
11.5 Exercises......................................................................................................... 143
Chapter 12 Three-Dimensional Dose Conformation................................................................... 145

12.1 Longitudinal Beam Conformance.................................................................. 145
12.1.1 Degrading Methods......................................................................... 149
12.1.1.1 Ridge Filter.................................................................. 149
12.1.1.2 Range Modulator Wheel.............................................. 150
12.1.1.3 Beam Current Modulation........................................... 150
12.1.1.4 Other Degrading Methods........................................... 151
12.1.2 Discrete Energy Changes................................................................ 152
12.1.3 Range Compensation....................................................................... 152
12.2 Transverse Beam Conformance by Scattering............................................... 153
12.2.1 Single Scattering............................................................................. 154
12.2.2 Double Scattering............................................................................ 155
12.2.2.1 Beam Properties........................................................... 156
12.2.2.2 Patient-Specific Hardware............................................ 156
12.2.2.3 Scattering System Components................................... 158
12.3 Transverse Beam Conformance by Scanning................................................ 158
12.3.1 Scanning Methods........................................................................... 159
12.3.2 General Description of Scanning.................................................... 159
12.3.3 Technical Scanning Delivery Techniques....................................... 160
12.3.3.1 Time- or Dose-Driven.................................................. 160
12.3.3.2 Variation of Speed and/or Current............................... 162
12.3.3.3 Dimensional Priority.................................................... 163
12.3.4 Clinical Delivery Styles.................................................................. 163
12.3.4.1 Uniform Scanning........................................................ 164
12.3.4.2 Single Field Uniform Dose.......................................... 164
12.3.4.3 Multi Field Delivery..................................................... 165
12.3.4.4 Distal Edge Tracking................................................... 166
12.3.5 Beam Motion (Not Patient Motion) Effects.................................... 166
12.3.6 Scanning Irradiation Time.............................................................. 167
x Contents
12.3.7
Time Sensitivities to Scanning Hardware....................................... 172
12.3.7.1 Time vs. Dose............................................................... 172
12.3.7.2 Time vs. Current.......................................................... 172
12.3.7.3 Time vs. Range............................................................. 173
12.3.7.4 Time vs. SAD............................................................... 173
12.3.7.5 Time vs. Magnet Current Ramp Rate.......................... 173
12.3.7.6 Time vs. Beam Off Time............................................. 174
12.3.7.7 Time vs. Energy Change Time.................................... 174
12.3.7.8 Other Considerations.................................................... 177
12.3.8 Dose Rate Tolerances...................................................................... 177
12.3.9 Pulsed Beams.................................................................................. 178
12.3.10 Scanning Hardware......................................................................... 180
12.3.10.1 Scanning Dipoles......................................................... 181
12.3.10.2 Dipole Contribution to Scanning Irradiation Time...... 183
12.3.11 Scanning Beam Parameters............................................................. 184
12.3.11.1 Static Beam Parameters............................................... 185
12.3.11.2 Transverse Dose Distribution, Penumbra
and Modulation............................................................ 185
12.3.12 Sensitivities (Scanning)................................................................... 188
12.3.13 Scan Patterns................................................................................... 189
12.3.14 The Effects of the Scanning Nozzle on the Beam Size.................. 190
12.3.14.1 Chamber and Windows................................................ 191
12.3.14.2 Downstream Materials................................................. 192
12.3.14.3 Influence of the Dipole Exit Window
on the Beam................................................................. 193
12.3.14.4 Influence of the Large Vacuum Window
on the Beam Width...................................................... 193
12.3.14.5 Effect of the Air Gap on the Beam Width................... 194
12.3.14.6 Beam Widths with Air Gaps Inside Target.................. 195
12.3.14.7 Effect of Range Shifter on Beam Width...................... 196
12.3.15 Scanning Control and Requirement Considerations....................... 198
12.3.15.1 More About Parameters............................................... 198
12.3.16 Faster Scanning Systems.................................................................200
12.3.17 Spreading Beams Summary............................................................ 201
12.3.18 How to Build a Scanning System....................................................202
12.4.1 Longitudinal Spreading................................................................... 203
12.4.2 Transverse Spreading...................................................................... 203
12.5 Exercises.........................................................................................................204
Chapter 13 Accelerator Systems..................................................................................................207

13.1 Accelerator Technology..................................................................................207
13.2 Time Structure of Accelerator Beams............................................................209
13.3 Cyclotron-Based Beam Production................................................................ 210
13.3.1 Phase Slippage................................................................................. 212
13.3.2 Cyclotron Focusing Effects............................................................. 213
13.3.3 Cyclotron Parameters...................................................................... 218
13.3.3.1 Energy.......................................................................... 218
13.3.3.2 Beam Phase Space Area.............................................. 219
13.3.3.3 Current......................................................................... 219
Contents xi
13.3.3.4 Time Dependence........................................................ 219

13.3.3.5 Operability................................................................... 219
13.3.3.6 Size............................................................................... 220
13.4 Degrader and Energy Selection System......................................................... 220
13.4.1 Beam Conditions Resulting from a Degrader................................. 221
13.4.2 Energy Selection System................................................................. 225
13.4.3 Degrader to Beamline Collimator Conditions................................ 230
13.4.4 Optics to Decouple Some Beamline Effects................................... 231
13.4.5 Degrader and ESS Summary.......................................................... 232
13.5 Synchrotron-Based Systems........................................................................... 233
13.5.1 Synchrotron Timing........................................................................ 234
13.5.2 Equation of Motion (General Case)................................................. 235
13.5.2.1 Interpretation of the Parameters
of the Equation of Motion............................................ 236
13.5.3 Relationship Between the Transfer Matrix
and the Trajectory Equation.......................................................... 237
13.5.4 Stability of a Closed Machine Particle Trajectory.......................... 237
13.5.5 And We’re Out of Here.................................................................... 239
13.5.6 Synchrotron Beam Parameters........................................................ 245
13.5.6.1 Energy.......................................................................... 245
13.5.6.2 Beam Phase Space....................................................... 245
13.5.6.3 Synchrotron Charges and Currents.............................. 245
13.5.6.4 Timing.......................................................................... 247
13.5.6.5 Cost.............................................................................. 249
13.5.7 Existing Synchrotron Systems........................................................ 250
13.5.8 The Future of Synchrotrons............................................................ 251
13.6 Accelerators.................................................................................................... 251
13.8 Exercises......................................................................................................... 253
Chapter 14 Gantries..................................................................................................................... 255

14.1 Introduction.................................................................................................... 255
14.2 Accelerator on a Gantry................................................................................. 255
14.2.1 Cyclotron on a Gantry..................................................................... 255
14.2.2 Synchrotron on a Gantry................................................................. 256
14.3 Gantry Geometry........................................................................................... 257
14.3.1 Issues Affecting the Gantry Design Parameters.............................260
14.3.1.1 Physical Implications of Clinical Issues...................... 261
14.3.1.2 Physical Implications of Magnetics............................. 263
14.3.1.3 Desirable Features........................................................264
14.3.1.4 Compact Gantry Parameters........................................ 265
14.4 Magnetic Spreading Geometry Considerations............................................. 265
14.5 Beam Optics Considerations..........................................................................266
14.5.1 Beam Phase Space Conditions at the Gantry Coupling.................. 267
14.5.2 Minimizing the Gantry Dispersion Function.................................. 267
14.5.2.1 Suppression of Dispersion............................................ 267
14.5.2.2 Momentum Bandwidth................................................ 267
14.5.2.3 Beam Profile for Beam Delivery.................................. 269
14.6 Gantry Examples............................................................................................ 269
14.6.1 High-Level Gantry Requirements................................................... 269
xii Contents
14.6.2 The Corkscrew Gantry.................................................................... 270

14.6.3 In-Plane Gantry............................................................................... 272
14.6.4 Compact Gantries............................................................................ 274
14.7 Additional Gantry Considerations.................................................................. 275
14.7.1 The Cost of Beam Size.................................................................... 275
14.7.2 Room Size Matters.......................................................................... 276
14.7.3 There Is No Isocenter...................................................................... 279
14.8 Gantry – Less or More?.................................................................................. 285
14.10 Exercises......................................................................................................... 286
Chapter 15 Safety in Radiotherapy.............................................................................................. 287

15.1 Processes to Raise Safety Awareness............................................................. 287
15.2 Introduction to Hazards and Mitigations........................................................ 288
15.3 Introduction to Risks and Criticality.............................................................. 290
15.3.1 Hierarchy of Risk Parameters......................................................... 291
15.4 Categories and Qualifiers of Risk.................................................................. 292
15.4.1 RPN, Risk and Categories............................................................... 292
15.4.2 Brute Force Calculation.................................................................. 294
15.4.3 Binary Combination........................................................................ 296
15.5 Models and Methodologies............................................................................ 296
15.5.1 Dominos, Swiss Cheese, But No Wine........................................... 297
15.5.2 FRAM............................................................................................. 297
15.5.3 STAMP............................................................................................ 298
15.5.4 Tools and Methods.......................................................................... 298
15.5.5 Practical Considerations..................................................................300
15.6 Hazard Analysis............................................................................................. 301
15.6.1 Pick a Hazard, Any Hazard.............................................................302
15.6.2 Identify a Subsystem.......................................................................302
15.6.3 Hazard Table................................................................................... 303
15.6.4 Radiotherapy Radiation Hazard
and Risk Examples��304
15.7 Failure Mode and Effects Analysis (FMEA)................................................. 305
15.7.1 FMEA Example..............................................................................306
15.7.2 FMEA Limitations.......................................................................... 310
15.8 Mitigation of Risk........................................................................................... 310
15.8.1 Training........................................................................................... 312
15.8.2 Communication............................................................................... 312
15.8.3 Standard Operating Procedures...................................................... 313
15.8.4 Equipment Design........................................................................... 314
15.9 Quality Assurance.......................................................................................... 315
15.9.1 Beam Quality Assurance................................................................ 315
15.9.2 Clinical and Machine Parameters................................................... 317
15.9.3 Instrument QA................................................................................. 320
15.9.4 How Often to Measure.................................................................... 320
15.10 Quick Quality Assurance............................................................................... 323
15.11 Beyond Safety................................................................................................. 324
15.13 Exercises......................................................................................................... 325
Contents xiii
Chapter 16 Sensitivities and Tolerances: Scattering.................................................................... 327

16.1 Methodology................................................................................................... 327
16.1.1 Input Beam Perturbations............................................................... 327
16.1.2 Component Perturbations: Second Scatterer................................... 329
16.1.3 Correction Capability...................................................................... 331
16.1.4 Ionization Chamber Perturbations.................................................. 331
16.1.5 Range Modulator Perturbations...................................................... 332
16.2 Discussion....................................................................................................... 333
Chapter 17 From Clinical to Technical Tolerances: Scanning.................................................... 335

17.1 The Chicken or the Egg.................................................................................. 335
17.2 The Acceptance Criteria................................................................................. 336
17.3 Gamma Index................................................................................................. 337
17.4 Tolerances.......................................................................................................340
17.4.1 Clinical Cases Used for the Study................................................... 342
17.4.2 Error Simulations............................................................................ 343
17.4.2.1 Accuracy vs. Reproducibility....................................... 343
17.4.2.2 Error Introduction........................................................344
17.4.3 Evaluation of Tolerances................................................................. 345
17.5 Flow to Technical Tolerances......................................................................... 351
17.5.1 Beam Range.................................................................................... 352
17.5.2 Beam Size........................................................................................ 353
17.5.3 Dose Weight.................................................................................... 354
17.5.4 Beam Position.................................................................................. 354
17.6 Exercises......................................................................................................... 355
Chapter 18 Afterword.................................................................................................................. 357
Acknowledgments......................................................................................................................... 359
Appendix A: Particle Therapy Facilities (as of June 2021)....................................................... 361
Appendix B: Some Useful Constants..........................................................................................367
Appendix C: Hazard Topics........................................................................................................369
Appendix D: Beam QA Frequency Possibility........................................................................... 371
Appendix E: Some Element and Compound Parameters......................................................... 373
Index............................................................................................................................................... 377
1 Introduction
The path from clinical requirements to technical implementation is filtered by the translation of
the modality to the technology. For example, the word ‘safe’ is defined in the context of the appli-
cation. The appropriate interpretation of that context is essential. It’s reasonable for there to be a
deterministic flow from requirements to implementation in any application. For particle therapy, it
helps to understand what clinical parameters affect the safety of a treatment, and then the filter is
constructed when determining how the technology can affect those parameters. Unsafe scenarios
are to be deduced or inferred and mitigated. This all begins as it ends by asking if you would feel
comfortable having a family member receive treatment.
Particle therapy is a multidisciplinary application that benefits from the insights of experts
in these disciplines. It is the intention to weave many of the disciplines together to construct
the framework for the application. This includes the context for the meanings and the relevance
of the parameters as well as limits imposed by the physics and engineering. Well, in fact, it is
difficult to be exhaustive in a book this size, so a sampling of this is offered, based on personal
experience. The book builds with a discussion of some tools, an introduction to the application
and the technology of the components that are needed. At almost every step the question, what
could go wrong, is asked. The statement that the system must be safe is insufficient. A look into
the clinical and technological considerations to achieve a realizable set of preconditions that
has safety at its core could be a sufficient start. This may not be done explicitly in every section
and for every subject, but it is hoped that there will be sufficient clarification for a safety filter
to be internalized.
Somewhat underlying the above is the approach of obtaining the necessary information about the
application before considering how to create the technical components. The information necessary
to learn about the applications to be presented can be acquired from many sources. The corollary to
this is that many good sources exist and it is not the author’s intent to reinvent the wheel. Yet, there
are many assumptions in these different sources, so it is hoped that fewer assumptions are made
herein. Some of the why is included with the what. If the reader finds the topics interesting and
needs additional perspective, that information probably exists.
The approach used is one that leads toward the identification of sensitivities and tolerances.
The technology is interpreted while applying a filter that includes the clinical application and
safety. Much of this filter has to do with considering what the tolerances are and what could go
wrong. It is not intended to fully design a system or even identify all the final specifications, but it
is hoped there is enough for many back of the envelope estimates. It’s probably best to get a new
box of envelopes now.
To accomplish this, it will be necessary to review some of the fundamental principles. It is
assumed that the audience for this book could be from various multidisciplinary fields. The
times that the author taught the ‘Medical Applications of Accelerators’ course at the US Particle
Accelerator School, the class usually included participants from both the medical and accelera-
tor communities. A foundation is offered that includes the clinical application, physical principles
related to the interaction of particles with matter, charged particle beam acceleration and transport
and even some engineering considerations. These are described at a level sufficient to build on in
the text. Almost everything that is introduced is used, although it may not always be obvious. Some
of it will be new for some and other topics will be review for others.
Putting all this together in one place at a level to understand how these can be used together is
the challenge. Much that is discussed in this book is placed in a context of safety, even if the word
‘safety’ is not used on every page. The word ‘safety’ is used several times in this introduction, to make
DOI: 10.1201/9781003123880-1 1
2 Particle Therapy Technology for Safe Treatment
up for that. Asking questions about how a parameter might affect a treatment and how a component
might affect a parameter will help the reader to get what’s intended from what’s been written. In the
end, the reader is rewarded with this. Sections entitled ‘what could go wrong’ are not meant to cause
concern, but only to heighten the thought process.
Part of the reason this book has been written after the author’s 45+ years in these fields is the
wish that a book like this existed when I started. I sincerely hope that you will find this contribution
helpful and perhaps enjoy a few smiles along the journey.
2 Evolution of Medical Particles
The discovery of particles at the atomic level and smaller and their interactions with matter has
been the subject of considerable interest for over 100 years. As the properties of the particles and
their interactions became better understood either quantitatively or qualitatively, applications to
use these particles were developed. To better study particles and their interactions, accelerators
have been constructed and the field of beam physics was developed. It was only recently (in the
last few decades) that the study of the physics of beams has become a legitimate field of investi-
gation. Generally, it was justified by the applications it served such as nuclear and high-energy
physics. Furthermore, it may be felt by some that nuclear and high-energy physics themselves are
only a stepping stone to develop useful applications for humanity. The ultimate application for
society may be medicine. The fundamental search for knowledge has always paid off whether it
has been the main goal of research or not. The key to applying the results of research is to have
in mind an overview of the relevant phenomena. Beginning with an understanding of what is
required for a particular application, the requirements can be followed to determine the details
of the implementation.
The applications of particles in medicine have been recognized from the earliest time that par-
ticles were discovered. The difficulty involves the preparation and delivery of these beams (from
naturally occurring beams [e.g. radioisotopes] to accelerator-produced beams). From the time, in
1895, when Roentgen discovered X-rays, and in 1913, when Coolidge developed the vacuum X-ray
tube, it has been shown that energetic particles can be useful for medical applications. It is clear
that there is a wide range of applications and, therefore, also a wide range of requirements for the
particles that must be considered.
Almost in parallel with the discovery of physical phenomena and the development of physical
devices, people started using these discoveries for treating those who were ill. Some of these dis-
coveries include:
• Magnetic fields
• High frequencies
• X-rays
• Electrons
• Protons
• Lasers
Most of the accelerators existing today are used for applications in the field of medicine.
While accelerators were originally introduced for research, the use of energetic particles for
medicine is natural. Medical applications require energetic beams (particles with energies
higher than thermal energies). Table 2.1 highlights some of the firsts in the chronology of
accelerators used for medicine.
Some of the early history is quite interesting and highlights the synergy and interactivity
of physics and medicine and money. In the 1930s, early trials at CalTech following the work
of Milliken and Lauritsen gave rise to a 750 keV X-ray generator and this was used for patient
treatment. Lauritsen’s students operated the machine during the day for patient treatments.
W.W. Kellogg (of Cornflakes) donated money to establish the Kellogg Labs at CalTech in 1931.
W.W. Kellogg was the brother of John Kellogg who ran the Battle Creek Sanitarium in Michigan
where James Case had installed the first 200 kV generator that was used for patient treatment.
DOI: 10.1201/9781003123880-2 3
TABLE 2.1
Highlights of Technology for Medicine
Year Energy Particle Event
1895 5 kV X-ray K. Roentgen discovers X-rays
1913 keV range X W.E. Coolidge develops vacuum X-ray tube
1931 80 keV H Ernest Lawrence develops a cyclotron (1939 Nobel Prize)
1937 1 MV X Air-insulated Van de Graff installed at Huntington Memorial Hospital (Boston)
1939 8 and 21 MeV d,n First medical cyclotron, Crocker Lab, Berkeley (USA) (R. Stone)
1940 1.25 MV X Pressure Van de Graaff accelerator at Massachusetts General Hospital
1946 Any MeV p, Ion Robert Wilson suggests medical use of protons and heavy ions
1949 20 MV X First patient treated with 20 MV X-rays from betatron at the University of Illinois
1950 8 MeV e, X First medical rf linear accelerator at Hammersmith Hospital in London
1954 100 MeV p, He First proton beam treatments at Berkeley
1954–1958 4 MeV e, X First 140° linac gantries in United Kingdom, New Zealand, Australia
1956 6 MeV E, X First United States 6 MeV linac in operation at Stanford Lane
1957 200 MeV p Proton synchrocyclotron beam treatments begin at Uppsala, Sweden
1959 50 MeV E First scanning electron beam (5–50 MeV) from linac for cancer (Chicago, USA)
1961 160 MeV p Proton beam treatments begin at the Harvard Cyclotron
1962 6 MeV e, X Isocentric (360o gantry) linear accelerator installed in the United States
1976 50 MeV Π First irradiation with a pion beam in an rf linear accelerator LAMPF (USA)
1982 30 MeV N First cyclotron used for neutron rotation therapy in the United States
1990 30 MeV N First superconducting cyclotron for neutron therapy (Harper, USA)
1990 250 MeV p First hospital-based proton synchrotron used for radiotherapy (Loma Linda, USA)
2001 230 MeV p First commercially built proton therapy system for a hospital (MGH, USA)
During that time, it was said that ‘such formidable installations would be prohibitive for the
average radiologist to consider and would be limited to those institutions with engineering and
physics skills available and should be centralized’. So was planted the seed for the first gen-
eration of particle therapy (PT). In the same time period, 1–2 MV generators were developed
by General Electric. In 1932, Van de Graff traveled from Princeton to MIT. He heard Dr. George
W. Holmes, a radiologist from MGH speak. He realized that his high-energy accelerators could be of
use. With a grant of $25,000, the first 1 MV Van de Graff generator was built for therapy. The first
patient was treated on March 1, 1937. Later in the 1930s, Donald Kerst developed the first betatron
at the University of Illinois. While he was a teaching assistant at the University of Wisconsin, he
took part in seminars at the University of Wisconsin General Hospital and recognized the utility
of high-energy electron accelerators in medicine. Later he worked for GE and developed a 20 MeV
medical betatron in 1942. In the 1950s, the first linear accelerator for therapy was installed in
Hammersmith Hospital in London and patients were treated from 1952 through 1969. Shortly
thereafter one was installed in Stanford. In 1946, Robert Wilson published an article recognizing
that the physics of the Bragg peak could be useful for medical therapy. Table 2.2 traces some of
the history of charged PT.
All in all, this is quite an interesting history. While it’s true that personal connections were cer-
tainly involved, the fact that physicists went to listen to medical talks, informally and vice-versa, is
Evolution of Medical Particles 5
TABLE 2.2
Charged Particle Therapy Milestones
Time Since the Start Time Since the
of the Universe Event Last Development
t = 0 second The universe was created ∞
t ~ 0.2 second Protons were created Δ = 0.2 second
t ~ 10 × 109 years First charge particle scanning – Northern and Southern Lights Δ = 1010 years
(see book cover)
t = 1780 Coulomb developed Coulomb’s laws Δ = 109 years
t = 1892 Lorentz introduced the Lorentz force Δ = 100 years
t = 1946 Wilson foresaw a clinical use Δ = 50 years
t = 1957 Beginning of proton therapy in Sweden Δ = 10 years
t = 1975 Koehler used double scattering w/protons Δ = 30 years
t = 1980s PTCOG formed to develop Particle Therapy Δ = 5 years
t = 1985 First hospital-based facility (Loma Linda) Δ = 5 years
t = 2001 Second hospital based (MGH), (1 Vendor IBA)
st
Δ ≈ 5 years
t > 2002 Proton facilities multiply Δ ≈ 1–2 years
t = 2008 First hospital-based scanned beam treatment Δ ≈ 6 years
t = 2021 I wrote this book Δ ≈ 13 years
something that may be lost in today’s society. Granted there were new innovations and the young
inventors were certainly looking for opportunities to utilize their systems. There is perhaps a not-
so-fine line between ‘Have Accelerator, Will Travel’ (an accelerator exists, can you use it?), and
identifying the requirements of a modality prior to developing a system for that. Still today, there
are people who want to offer different accelerator ideas for use in PT. So far, no accelerators, other
than the cyclotron and synchrotron, have proved successful in this field.
Accelerators of various types are used to generate these beams. The accelerator is one of the key
components of this equipment, and its continued future will be dictated by its ability to accommo-
date evolving clinical requirements. It is not the only, or possibly even the most important technical
component. Beam delivery systems tailor the beam for treatment. The field of PT is quickly growing
and yet its more widespread adoption is limited by size and cost. In order to fully realize the benefits
of this modality, the equipment used to generate and deliver the beam is evolving.
The growth of the number of PT facilities in the world is fascinating to follow. While it’s clear
that, at the start, people with forward-thinking minds, usually at academic medical centers, would
be part of the inception and the early adoption of the modality, it’s perhaps not as obvious what
would be the next step. One can look at a map of the United States to partially answer that ques-
tion. Figure 2.1 is a population density map of the United States with the regions of high population
density denoted by darker shades.
Presently, the location of PT centers in the United States is shown in Figure 2.2. Note that all these
centers are located in regions of high population density. There are still high density population centers
lacking PT nearby, particularly in the center of the country. However, considering the distribution of
the high population centers in the United States, there are wide regions between high density popula-
tions and it is likely that the distance to travel for many will be prohibitive, so there is likely to be more
located in lower density areas. The same logic holds for Europe and one can imagine the equivalent
FIGURE 2.1 US population density map.
FIGURE 2.2 North American particle therapy facilities.

logic for China, which has vast regions with population densities higher than that in the United States.
A recent accounting of the proton centers in the world is shown in Figure 2.3. Of note is the concentra-
tion between 20°N and 66°N latitude.
Some years ago, treatments were suspended in the one PT treatment center in South Africa.
A table with more information about these facilities is in Appendix A. The growth over time has
been almost exponential as shown in Figure 2.4. Projections forward (after the break in the curve)
FIGURE 2.3 World particle therapy facilities.
FIGURE 2.4 Particle therapy number history.

seem flatter, but that has always been the case (for projections), and even more so now in the middle
(end?) of the coronavirus pandemic. The distribution across the world is shown in the pie chart of
Figure 2.5. If a region is not included, PT does not yet exist there. Those same regions are plotted in
Figure 2.6(left) for megavoltage (e.g. Linac)-based therapy (Japan is part of Asia). They are remark-
ably similar. However, Figure 2.6(right) shows all the MV therapy in the world and the picture
changes with the numbers in Africa and South America.
FIGURE 2.5 Distribution of particle therapy.
FIGURE 2.6 MV therapy world distribution (left) and MV therapy world distribution (full) (right).
It is instructive to examine some of these regions further by socioeconomic factors. Table 2.3
includes information about the main geographic regions in PT. The population is given in mil-
lions and the number of PT rooms (not just facilities) is listed, including currently operating, under
construction and in planning stages. This total is compared to the population in that region. The
rightmost columns are millions of people per PT room.
Figure 2.7 contains the same data sorted in different ways. The gross domestic product (GDP)
and GDP/Capita (GDP/Cap) are plotted with the millions of patients per room total from Table 2.3.
The graph in Figure 2.7(top) shows that the countries with the lowest population per room are also
in the higher GDP category, so there is a direct relation between the resources of a country and
the number of PT facilities constructed. This results from both government and industry factors in
those countries. Figure 2.7(bottom) shows the same data sorted with increasing GDP. This shows
a couple of things. The GDP/Cap while overall showing the same trend as the GDP does show
TABLE 2.3
Regional Statistics
Population Rooms Under Sub In Millions Mill/Rm
Region Millions Operating Construction Total Planning Total Per Room Incl Planning
Asia 4,336 28 62 90 20 110 48.18 39.42
EU 508 82 11 93 12 105 5.46 4.84
Japan 126.8 51 9 60 6 66 2.11 1.92
United States 327.2 94 14 108 0 108 3.03 3.03
Russia 144.5 7 5 12 2 14 12.04 10.32
262 101 363 40 403
FIGURE 2.7 Plot of various socioeconomic data by region (top) and plot of various socioeconomic
data by region resorted (bottom).
some fluctuations. The correlation, however, between GDP/Cap and millions/room is not smooth
(the GDP/Cap is more or less flat for the first two points, but the Mill/Rm is not). Perhaps the main
reason is the situation of China. Without China, the GDP/Cap would have a smooth correlation
with the inverse of the millions/room. This is likely to start changing fairly soon. Thus, the correla-
tion of PT that is available is closer to the GDP/Cap than to the GDP. China has a higher GDP but
with a huge population.
All of this points to the fact that the costs of PT seem to be an impediment to even faster growth.
Given the similar distribution between MV and PT therapy, it isn’t about the modality. Differences
include a larger proportion of electron accelerators in Asia and a larger proportion of particle facili-
ties in Japan. Therefore, there seems to be cultural aspects to the distribution also.
It can be noted that some of this has to do with the capital cost of a particle accelerator. Many
who read this sentence could believe that this is a sarcastic statement of the obvious. However, there
are some misconceptions. It is important to compare apples and oranges when comparing the costs
of a PT system with an electron linac system for photon therapy. Some factors for proton therapy
facilities are listed in Table 2.4.
TABLE 2.4
Proton Therapy Capital Costs
Factor Proton Photon
Building $20,000,000(1) $0? (within existing building)
Equipment $50,000,000(2) $6,000,000
No. of rooms 3 1
Lifetime 20 (maybe 30) 10(3)
1 Many systems are quoted as costing $100M or double of that. Most of the time, this includes the
construction of an entirely new cancer center with diagnostic equipment and other services. This cost
should not be directly compared. The figure used is that of a modest new building, but it can be pos-
sible to install proton equipment in an existing building (e.g. as was done at MGH).
2 Most proton centers include multiple treatment rooms. The cost shown is for a 3-room system.
3 Medical linacs are not built for a long lifetime and sometimes used to have gantry bearing issues, for
example. But really the issue is that new features are introduced and medical centers would like to
improve their patient treatment capabilities. Depreciation is a standard part of owning a linac.
Depreciation is not generally taken for PT.
With these considerations, the total cost of a proton facility/room/10 years is $8.3M (or $10M
depending on how well one negotiates), which is more directly comparable to the $6M linac.
Beyond this, an article by Martin Jermann and Michael Goitein analyzed various other cost
considerations, including operations, business expenses, building, infrastructure, preventive main-
tenance etc. The conclusion was that the cost per treatment of a proton system is 2.39 times the cost
of the X-ray system. However, a critical challenge to these numbers can identify some specific ques-
tions. A subjective, devil’s advocate response to these questions can include:
• The project management (PM) costs of proton equipment should not be significantly higher
than X-ray equipment. Do not include the PM costs of a brand new cancer center.
• The building cost has been mentioned in Table 2.4; however considering a new building
for X-ray equipment and a new building for a single-room proton, equipment could be
comparable, especially with modular approaches being developed.
• Equipment operations should be within a factor of 2 of each other.
• It’s unclear why the business costs should be much different, now that proton therapy
installation is more mature.
• The treatment time per fraction is closer and closer to X-ray beam setup and delivery.
All in all, the author has analyzed the various factors and the spreadsheet shows that it should
be possible to achieve similar patient throughput and the cost/treatment can be closer than a factor
of 1.2. New development of systems must take into account these factors to ensure that the actual
costs are known, and therefore the perceived cost differential is minimized. Then the impediment
to faster growth can be reduced. Perception is generally taken as reality. It remains for reality to
influence the perception by example. MGH showed that it’s possible to install a proton beam inside
an existing and operating radiotherapy department. Single-room systems are becoming more avail-
able. Community health centers are now offering proton therapy. The field is changing and growing.
3 A Personal Historical
Perspective
The evolution of particle therapy is now in its fourth generation. In 1946, Robert Wilson published
the famous observation that the behavior of charged particles in matter could be beneficial for the
treatment of cancer. At that time, production of charged particles with the energy and beam prop-
erties necessary for particle therapy was only possible in national accelerator laboratories and yet
treatments began there over 50 years ago. In 1957, patient treatments began in Sweden and early
adopters included Berkeley National Laboratory, the Harvard Cyclotron Laboratory, UC Davis,
Fermi National Accelerator Laboratory (uncharged neutrons). The development actually paralleled,
in time, the start of linac-based electron and photon therapy, but that modality was possible to con-
struct by private industry vendors, and it spread quickly.
In the 1980s–1990s, it was imagined that proton therapy could be possible in a hospital environ-
ment. The second generation of particle therapy began when Loma Linda built the first hospital-
based system, with the help of Fermilab and commercial firms. A wonderful collaboration among
interested parties to specify the requirements of that facility saw the formation of the Particle
Therapy Co-Operative Group (PTCOG), started by Jim Slater, Michael Goitein and Herman Suit.
Next, the Massachusetts General Hospital constructed the second hospital-based system, but the
first one entirely (well almost) constructed by a commercial vendor, IBA. Around that time, NCC
East in Japan also constructed a similar facility with the help of Sumitomo Heavy Industries.
I joined MGH in 1993 after spending 15 years at MIT involved in nuclear and accelerator phys-
ics. I was hired at MIT by an individual who may have had the most influence in my professional
life. I was fortunate to be at a program advisory committee meeting where, as a student, I was to
present an experimental proposal (which was accepted). It was not typical for a student to present
a proposal, so I was nervous. I was waiting my turn in the back of the room when a person walked
in wearing a torn sweater with stained fingers, unkempt hair and a scruffy beard. He sat in a chair,
crossed his legs in a lotus position and started to roll something that would be smoked. I couldn’t
believe he had the audacity to enter this high-level meeting and I lost focus on what was happening
at the front of the room. Well, what was happening was that several individuals got into a disagree-
ment about physics principles and experimental techniques. This went on for some minutes without
any resolution. Then, this individual, who I thought shouldn’t have been in the room, got up from
his chair, began to speak and everyone went silent. He categorically clarified every point of confu-
sion, sat down and lit his smoke. I told myself that I wanted to work with him one day. It was quite
a happy day when I was talking to Phil Sargent a few years later about my employment offers (there
were no open positions at the time at MIT), when he said – no don’t go there, I’ll hire you. At MIT,
I designed a beam recirculation system for a 200 m long high precision linac. I also designed a one
GeV electron pulse stretcher/storage/synchrotron for nuclear physics. (We built both and they oper-
ated well.) Through it all I owe much to Phil, Bill Turchinetz and Peter Demos.
During an external review for the ring, a reviewer, Jose Alonso from Berkeley, told us about the
proton therapy initiative at MGH. I had some peripheral familiarity with the medical field at that
time, having had the high pleasure of interacting with Jake Haimson, who was the designer of the
MIT-Bates accelerator (and Linacs in Saclay and Saskatoon among many other things). It turned out
he was engaged for the MIT-Bates design after working with Varian on the design and construction
of one of the first 360-degree rotatable Linac gantries as head of accelerator research. And before
that was responsible for hospital Linac installations for MVEC. That company installed the first
medical Linac in Hammersmith Hospitals in 1953. The patents in the early 1960s for a linac on a
DOI: 10.1201/9781003123880-3 13
gantry all bear his name. He also invented the technology for the first fast CT scanner, the Imatron,
using plasma-focused electron beams, among other innovations in medical technology. Imagine
my surprise a decade or two later when I met his friend Sarah Donaldson and found out who she
was. During my work on the electron storage/stretcher ring, I had another honor to interact with
Mikael Eriksson of Lund Sweden, famous for among other things the Max-Lab Lund synchrotrons.
Earlier in his career, he contributed (may be too weak a word) to the MM50 electron microtron, an
accelerator for medical treatment. Other groups were interested in high duty factor pulse-stretching
synchrotrons, such as the team in Saskatoon. I interacted with so many talented individuals, includ-
ing Dennis Skopik, but special mention is for one who became a longtime mentor of mine (and
other friends of mine). He was Roger Servranckx coming to Saskatchewan by way of Belgium and
the Belgium Congo. Beyond all the technical aspects of ring design, I learned that there were more
beers than pilsners. I do want to mention here my interactions with Klaus Halbach and Harald Enge,
both fathers of magnetics and optics. I, myself, benefitted from a look into Klaus’s famous black
book (which later was published as an aqua green book)! Harald, who used to use a draftspersons
table to trace rays, before computers, was the optics designer of the Loma Linda proton therapy
corkscrew gantry, and the first compact gantry for PSI. Eventually, I joined MGH during the pro-
posal stage and met Yves Jongen of IBA. I learned much of what I know about cyclotrons from
him. Yves tried to convince me that two people can disagree on a technical solution while both are
right. I’m not sure that I ever fully bought into that. The rest of my cyclotron education comes from
my Sensei Yukio Kumata whose deep experience he openly shared. Figure 3.1 summarizes some
of this. This isn’t a full acknowledgment list (there are so many more friends and colleagues), but a
short digression from the narrative to which I now return.
FIGURE 3.1 Author’s mentor tree.
Considering the unfortunate dwindling funding situation for nuclear physics in the United
States, at the time and the extremely interesting sounding health-care project, I inquired about the
A Personal Historical Perspective 15
opportunities at MGH and joined the project in the proposal stages. There were cultural differences
to which I had to adapt. Physicians used 35 mm slides, not ‘dirty’ overhead transparencies with
‘fingerprints’. Some say that there were political machinations, of which I was unaware, but eventu-
ally MGH was awarded funds for the construction of a proton facility. The history of this award is
not without some interest. In the 1980s, the promise of neutron therapy was courted. In fact, the
National Cancer Institute (NCI) awarded funds for the production of several neutron therapy sys-
tems that were cyclotron based. Not all these facilities were completed and a primary company had
some issues. This was the last time that the NCI provided funding for the construction of medical
therapy equipment of this magnitude. The funds awarded to MGH were for the construction of the
building, not the technical equipment.
Initially, we had enough funds for only one gantry. However, some crafty contractual terms (which
I suggested) led to the possibility to consider two gantries when I redesigned the proposed beamline,
considerably reducing the cost of that portion of the project. Finally, with the help of my colleagues
from MIT and the MGH technical team, we constructed the fixed beamlines that were able to accom-
modate the eye treatment station and the stereotactic radiosurgery station that were in use at Harvard. I
was told by Michael Goitein and Al Smith, at the start of my tenure at MGH, that it would be a boring
job in that everything would be done by the outside company and the system would run without any
intervention needed. I’m not sure if it was good or bad, but it was never actually boring.
At the time, in this second generation of particle therapy, it was thought by wise people in the
field that the need for proton therapy in the United States would be three facilities. This is much
like the feeling in the 1930s about the ‘formidable installations’ of the early accelerators. This
would include the Loma Linda facility, the MGH facility and one in the Midwest. Some years later,
a facility was constructed as an outgrowth of the Indiana University Cyclotron Facility (IUCF),
called the Midwest Proton Radiotherapy Institute (MPRI). I was happy to see this. IUCF was the
proton sister lab to the MIT Bates lab in which I had worked and the community was already con-
nected and growing. However, the original predictions fell far short of reality. With particle therapy
offering equal or better efficacy (and note here that I am including the word equal), one can argue
that this modality can serve a large fraction of the existing cohorts of radiotherapy patients. With
thousands of linac-based therapy systems, this translated to some more than three particle facilities
in the United States.
As particle therapy expanded, the capabilities of photon therapy also grew, with IMRT, for exam-
ple. In addition, the resources within the particle therapy community grew as well as the desire to
improve the beam delivery capabilities. In the early electron beam days, Anders Brahme explored
the use of scattered beam delivery and scanned beam delivery. (Well, truth be told, if someone is
thinking about something in the field today, Brahme had probably already considered or tested it
much earlier.) Some decades later, the scanning beam for protons found its way in Japan, Berkeley,
and for dedicated clinical use at PSI. These were still in a laboratory environment. In 2008, Hitachi
installed a scanning system in MD Anderson, and MGH did the same. I was very proud to have
worked with a talented team, including MGH, IBA and Pyramid Technical Consultants to create
the scanning beam modality at MGH in a hospital environment. Since then many other centers have
benefited from the same technology. This began the third generation of particle therapy.
The first adopters of this ‘new’ modality were academic medical centers. Owing to their larger
patient population, multiroom centers were constructed. This is reminiscent of the MM50 electron
microtron that was built for electron/photon therapy serving two rooms. The multiroom centers,
however, come with a higher building cost. Sometimes, complete cancer centers were constructed
around them. This greatly swayed the cost of the proton therapy facility when compared with that
of a linac in a bunker in an existing radiotherapy department. A system with three rooms might
last two or three times as long as a linac. In addition, a new building structure is not always needed
and is not comparable with a single room linac cost. If one properly includes these numbers, it
turns out that the capital cost may be within a factor of 2 or less per room. The academic centers
did need multiple rooms given their patient population. As the number of facilities grew, many of
the academic centers had their own systems and the industry focused more on the needs of smaller
hospitals. In addition, some companies were formed with the idea of providing freestanding systems
to serve community-based environments. In addition, industry began to build single-room systems
and reduce the cost of the components. This contributed to the start of what has been called ‘the
democratization of proton therapy’. This began the fourth generation of facilities. Much of this last
generation is focused on protons since heavier particles continue to be a larger, more expensive sys-
tem. However, superconducting technology and good engineering have contributed to heavier ion
gantries (pun intended) at such places as Heidelberg and HIMAC.
Scanning has indeed improved the conformity of particle radiotherapy. However, there is still
more to be gained. There are margins that may be possible to reduce, if clinically warranted and
mitigation of organ motion to address. The integral dose can be significantly reduced with available
technology. There are more papers being published about adaptive therapy, and work is ongoing
toward the development of proton tomography. This can all lead toward the onset of the fifth genera-
tion of particle therapy.
As in the past, what has been thought about before can come back to the present. There is now
renewed interest in exploring the effects of high dose rate and striped beams. Very high dose rate
with high doses seems to spare healthy tissue but control diseased tissue, and beams that are spa-
tially separated in that region seem to spare tissue and only affect the tissue when the beam spreads
out filling the spaces in between. This, inspired by the reintroduction of biology in particle therapy,
instead of simply assuming proton therapy has an RBE of 1.1, is giving rise to new possibilities in
the application of particle therapy. This may also be the beginning of the sixth generation – perhaps
more medicine and biology than physics and technology.
To date, there are about 105 particle therapy facilities in the world, with strong growth continu-
ing. The growth rate does follow the economy, and the effect of COVID has been noticeable. As
President of PTCOG with the help and support of Martin Jermann, I have personally seen a rapid
growth in the availability of particle therapy to the patient population that needs it. In addition, the
people involved in this growth are motivated, energetic and contribute significantly to the commu-
nity. It is and has been very rewarding to be a part of this.
4 Flow of Requirements
4.1 DIRECT REQUIREMENTS

At the highest level, the goals of radiotherapy are to:
• Deliver the required dose

• Deliver that dose with the prescribed dose distribution and
• Deliver that dose in the right place
• Do it safely
• Keep the patients and staff safe and happy
These goals are achieved through the careful identification and cross referencing of require-
ments. The requirements of the systems that enable particle therapy are interrelated. Above all,
the overall system design and design of the specific components must be safe and must satisfy the
desired clinical specifications. As part of this, the clinical beam requirements and sensitivities
should be defined and then it should be determined which ones are related to the technology. The
chart in Figure 4.1 indicates the flow of requirements, in some semblance of order from require-
ments to technology.
FIGURE 4.1 Flow of requirements.
Starting from any position in the chart other than the top will likely result in compromised treat-
ment parameters. Note that the clinical requirements are buffered, in part, by the delivery modality.
This is so, because the delivery modality will affect the type of beam that is needed to achieve a
desired clinical goal, and therefore what the beam requirements will be. For some parameters, the
characteristics of the accelerator are critical to the beam delivery process, and for other parameters
they are almost irrelevant Furthermore, at each step of the analysis, the safety requirements must
be evaluated in order to be sure that they are all captured and well translated before designing the
component, such as the accelerator. Note how safety and user requirements flow into every level.
Clinical beam parameters, such as dose, dose rate, range, distal falloff, penumbra and dose con-
formity, among others, will be associated with beam parameters such as beam time structure, beam
current, beam energy, beam shape, size and position. When discussing the beam production and
delivery technology, it is always important to remember and associate the beam parameters with the
clinical parameters; however, the association can be one to many or many to one. In addition, and
perhaps even more importantly, the tolerances associated with each of these parameters are critical.
A change in the beam range, or position, or shape could deposit dose outside the target, especially
in the case of beam scanning.
DOI: 10.1201/9781003123880-4 17
The beam delivery system, which is in between the accelerator and the patient, will play a
role in how the safe delivery of clinical beam parameters is related to the accelerator param-
eters. It is necessary to first understand these dependencies and to identify potential safety
concerns. Figure 4.2 shows an example of what a high level dependency analysis might yield. Most
of these terms will be discussed in the book.
FIGURE 4.2 Parameter dependencies.
There are many links, but just to pick one, consider the penumbra. If the beam spreading modal-
ity under consideration is scattering, a partial list of some of the parameters that will affect the beam
penumbra includes the following:
• Gantry optics
• Beam emittance
• SAD
• Collimator
• Air gap
In the case where the beam spreading modality is scanning, the beam size and scanning optics
will affect the penumbra. These dependencies have real consequences.
As an example of this, Table 4.1 shows a few possible parameters and the flow of values from the
clinical values to the beam parameters and then to an accelerator parameter that is involved for the
case of a beam scanning delivery system.
Many of the terms used in this section will be defined in subsequent chapters. Keep these con-
siderations in mind while studying this book.
Flow of Requirements 19
TABLE 4.1
Sample of Flow from Clinical Values to Accelerator Parameters
Clinical Parameter Sample Clinical Value Beam Parameter Accelerator Parameter
Dose rate 1 Gy/L min ~100 × 109 protons/min Beam current
Range 32 cm (in water) 226.2 MeV protons Beam energy
Scanned-beam penumbra 80–20% falloff = 3.4 mm (in air) 4 mm sigma (e−1/2 for a Beam size, beam emittance
Gaussian beam)
4.2 DEVELOPMENTAL REQUIREMENTS

It may also be useful to consider the evolution of beam delivery in the near future. The following
are some of the recent themes that have been driving the development of particle therapy. Evolution
to achieve improved treatment parameters is also a requirement.
• Beam scanning (‘pencil’ or ‘crayon’). The method of choice for spreading the beam is beam
scanning: more particularly, using magnetic fields to move the beam across the target, thus
‘painting’ the desired area. The size of the ‘brush’ is the beam size, which is strongly
related to the properties of the largely unperturbed beam emerging from the accelerator
(and the subsequent focusing systems). The depth of penetration of the beam is primarily
determined by the beam energy. The desire is to do this quickly.
• Image-guided radiation therapy (IGRT). The beam position is determined by the use of
imaging technology of some sort. For moving targets, the beam properties may require
adjustment by feedback during the motion. With charged particles it is possible to image
anatomy and directly determine the effective stopping power along the path to the target.
Particle radiography and tomography depend upon the ability of the beam to penetrate the
patient, and thus require appropriate beam energy.
• Adaptive radiotherapy. Imaging techniques and treatment planning must evolve to a point
where a target today that has a different geometry from yesterday (or a minute ago) can be
effectively treated. The treatment parameters need to be modified almost on-the-fly. This
has implications not only for beam delivery but also for quality assurance.
• End of range. Currently, there is some uncertainty in the range of the particles in the
patient. This uncertainty results from errors in conversion from X-ray-based imaging and
from organ motion or redistribution. Such range information can potentially be obtained
more accurately using particle-based imaging or other on-line detection methods, which
would then require adjustment of the delivered beam energy during delivery.
• Ions. It has been suggested that the treatment of a single tumor could benefit from the use
of multiple particles with different values of linear energy transfer, delivered during a
single irradiation.
• Effective cost. It is a continuing concern that the capital investment is higher for particle
facilities than for some other modalities. The basis of that conclusion may be from inap-
propriate comparisons. In any case, the goal must be to achieve a cost balance in terms
of capital investment, patient throughput and treatment accuracy and efficacy so as to be
competitive with other modalities.
Consideration of the above goals of particle therapy, as well as the specific clinical requirements
placed on the beam parameters, could and probably should be factored into the requirements for
the technology.
5 External Beam Systems
Therapeutic treatment using external beams involves the use of energetic beams to ameliorate
abnormal conditions in patients. The beams come from a source external to the patient which are
generated and controlled by various systems. They are used either to kill abnormal cells or pre-
vent their reproduction or multiplication. The energetic particles in the external beams lose energy
when entering the body (one way or another) and this energy in turn leads to damage of the cells.
Examples of some types of external beam therapy systems include
1. X-ray therapy
2. Electron beam therapy
3. Particle beam therapy
The key goals of radiotherapy are to
• Deliver the required dose (including the required overall dose)

• Deliver that dose in the right locations
An extension of these two points is to deliver the prescribed dose distribution within the three
dimensional volume of the target at the appropriate time.
That seems simple enough. However, understanding how each and every component that is to be
used, affects the clinical beam and how the parameters of the clinical beam can affect the patient is
the reason why it took some 50 years to develop modern radiotherapy systems.
Any and all of these systems include a fairly large number of components that serve to produce
and deliver the therapeutic beam. One must clearly define the clinical beam requirements and deter-
mine how these are related to the system design. The ‘system design’ can be defined to include three
primary components.
• Beam production – Produce the beam at the desired energy level (using an accelerator) and
direct the beam to the room in which treatment takes place. This could include a particle
accelerator and a beam transport system.
• Beam delivery – Take the beam from the beam production system and deliver it to a desired
point in space with the prescribed clinical parameters. This includes the components that
will tailor the beam to match the needs of the patient and components to orient the beam
relative to the patient, such as a gantry.
• Positioning – Identify the location in the patient which is to be the target of the beam and
position the patient in such a way that this target is coincident with the beam from the beam
delivery system. This includes components that image the target and immobilize and posi-
tion the patient.
• Each of these components has controls and systems of safety included.
These components can be organized as in Figure 5.1.

For some parameters, the characteristics of the systems are critical to the beam delivery process,
and for other parameters, they are almost irrelevant. As much as possible, one must design the
system to achieve all the desired clinical goals. While figuring out how to apply an existing system
to some clinical goals can work temporarily, designing a system with the primary purpose of safe
DOI: 10.1201/9781003123880-5 21
FIGURE 5.1 Parts of a particle therapy system.
therapy is optimal. The components used will depend on the choices. Figure 5.2 is an example
layout of the components of a cyclotron-based particle therapy system which includes the beam pro-
duction components composed of the accelerator (cyclotron) and energy selection system; the beam
transport components, a gantry and the nozzle/beam delivery components.
FIGURE 5.2 Layout of a cyclotron-based particle therapy system.

External Beam Systems 23
The modality discussed in this book is that of an external charged particle beam that is directed
to the target. In Figure 5.3, with the beam coming in from the left, slices of a spheroidal target, are
in the transverse plane. With respect to that beam, one can define four coordinates in the target.
• The longitudinal direction (z) also known as the depth direction. It is the direction of the
traveling beam in the patient.
• The transverse directions (x and y), or the plane perpendicular to the depth.
• The time (t), of which the other three directions are a function, i.e. x(t), y(t) and z(t).
FIGURE 5.3 Target planes.
These directions, or parameters that define some of the beam characteristics, are important in
describing not only the desired action of the external beam, but also the technology required to
control the beam and the systems of safety that must be implemented.
All of these systems are integrated to some extent, depending upon how modularized the designers
have made them. One subjective opinion about how these systems could interact is that they should be
modular. There are various levels of this modularity. At the highest level, the beam production system
defined earlier controls the trajectory of the beam to pass through a specific point in space. This is handed
off to the beam delivery system which tailors the beam for patient treatment and directs it to the patient
treatment location. The patient targeting system positions the patient, so that the target is centered at that
point in space. Variations of this are possible. The patient targetry can be implemented quite indepen-
dently. Interfaces that are physical and control related must, of course, be carefully integrated. Of these
systems, this book does not cover the controls architecture, patient targeting and positioning systems.
There is a long list of ‘ilities’ that are important to include in system design including, but not
limited to
• Useability
• Maintainability
• Operability
• Upgradeability
• Diagnosability
If any one component is too tightly integrated with all the others, it may be hard to upgrade the
system when needed. Similarly, when, in the inevitable eventuality, it is necessary to fix things, too
tightly coupling components can make it very difficult to diagnose where an issue might lie or how
best to repair it. Repairability is directly related to forms of safety.
Right from the start, the system design has to take possible failure modes and errors into account.
Strategies of mitigation of potential errors are critical to integrate at the outset. Having auxiliary
systems that are redundant is great, but not a substitute for good system design. Questions like how
many layers of redundancy and should two out of three logic be used, must be answered. A system
that does not work is not safe, since the patient is likely not getting the needed treatment.
At every step along the way, in this book, systems are torn apart to their base purpose. The ques-
tion, what can go wrong is addressed at the appropriate intervals. While it might not be referred to
in every chapter and section, this information will eventually be used to help define tolerances and
determine the sensitivities of the clinical treatment and equipment error. When reading much of this
book, ask what does this do? Why does it do this? How does it do this? What should be considered
to implement it safely?
6 How to Damage Unwanted Cells
It is desired to eliminate unwanted cells in living tissue. There are a number of considerations when
identifying the optimal approach. Many references discuss the medicine, radiobiology, chemistry and
physics of these considerations. The goal in this chapter is to identify some parameters that would pro-
vide insight to the technology and safety considerations applied to particle therapy. This short section
does not include the complexity and depth of the relevant biology underlying the modality.
Eradicating unwanted cells can be done by killing the cell outright or by inhibiting its ability to
reproduce. This can be done by depositing sufficient energy into the cell or introducing chemicals that
react with the cell components to destroy the cell. One can, alternatively, be more controlled about the
amount of energy or chemicals that are introduced, and use them to affect the DNA of the cell in such
a way that the cell cannot reproduce. One of the most important cellular functions is the ability of the
cell to divide. If a cell retains this ability following irradiation, it is said to have survived.
Biological systems are sensitive to radiation. Take for granted that depositing 5 Joules(J) in 1
kilogram(kg), which is written as 5J/kg, in a body or cell is sufficient to disrupt its life cycle. A cell
is mostly made up of water.
• Therefore, converting this energy into calories, 5 J/kg = 5/4.18 cal/kg.

• The specific heat of water is 103 cal/(kg °C)
• And, ΔT = 5/4.18 cal/kg × 10 -3 kg/cal C = 1.195 × 10 -3 °C
Thus, this amount of energy raised the temperature of the cell by about a millidegree, or not much
of a temperature rise! So the damage must come from other factors. This energy, once released,
gives rise to a variety of interactions that may damage molecules of biological importance such
as DNA and so lead to cell death or the inability to divide. Basically there are direct effects and
indirect effects. Figure 6.1 illustrates the difference between direct and indirect actions of ionizing
radiation that can affect the DNA.
FIGURE 6.1 Types of DNA damage.
DOI: 10.1201/9781003123880-6 25
6.1 DIRECT EFFECTS

A direct action is that of the ionizations produced by energy released directly to break the bonds of
a specific structural component of an organism, such as
Molecular:
• Protein
• Enzyme
• DNA
Complex cell structure:

• Chromosome
• Ribosome
• Mitochondria
6.2 INDIRECT EFFECTS

Since biological material is primarily composed of water, most of the damage resulting from ion-
izing radiation comes from chemistry. Here exists a remarkable confluence of physics, chemistry
and biology. The viability of a cell can be affected indirectly through radiochemical effects. Cells
are 70% water (H2O) and the energy released from radiation is absorbed in the water. From this, the
following reactions can occur:
H 2 O + energy → H 2 O + + e − → H 2 O + e − aqueous (6.1)
or H 2 O + →·OH + H + (6.2)
or H 2 O + energy → H 2 O* → H·+·OH, (6.3)
where the •OH is a hydroxyl radical, a molecule with an unpaired electron and an excited state is
marked by (*). The products are very reactive acid and base radicals. A radical is a molecule that has
a relatively high energy content due to the presence of an unpaired electron. (Lack of spin pairing
decreases the stability of the molecule.) This results in reactions like oxidation (loss of the electron)
or reduction (gaining of an electron).
This was first recognized by Fricke in 1927, followed by a clearer understanding in the 1960s.
The reactions can cause damage to the DNA – as depicted in Figure 6.1. The types of DNA dam-
age that can occur include
1. Base changes
2. Breaks
3. Cross links
Molecular masses obtained from radiation studies are different than those obtained without
radiation due to these chemical reactions that are initiated by the released energy. In the presence
of oxygen, the ionized molecule combines with oxygen forming a peroxyl radical that wreaks havoc
with the target. When oxygen is not present, any ionized molecule might just be reconstituted.
Therefore, there is an advantage to having oxygen to help the reaction. This is called the oxygen
enhancement effect. The ratio of the dose required to achieve a level of cell inactivation without
oxygen (anaerobic) to that required to achieve the same level of inactivation with oxygen (aerobic) is
called the oxygen enhancement ratio (OER).
Cancer cells may develop faster than the vascular systems needed to properly support them, but
they can survive, and hence, some cancer cells are anaerobic. Thus, it could be that cancer cells are
How to Damage Unwanted Cells 27
less radiosensitive than the surrounding healthy tissue. However, different radiations differ in their
ability to cause a specific biological effect. The radiobiological efficiency (RBE) is defined as the
ratio of the dose of X or γ rays needed to produce a specific biological effect compared with to
the dose of the radiation medium in question needed to produce the same effect. Therefore, the dose
equivalent of a particular charged particle = RBE × dose (X).
It is important to minimize collateral damage, in the sense that it is important to protect the nor-
mal cells. So it would be best to localize the effects and consider the concept of a target. Charged
particles produce excited and ionized atoms and molecules. The distance between these events
depends upon the particle and the energy it releases per unit distance. The linear energy transfer
(LET), in general, is the energy transferred per unit distance. The range of the particle will be
related to the incident energy of the particle divided by the average LET (which will change as it
loses energy). There are various categories of this having to do with where the energy is lost. The
stopping power is related to the LET and will be discussed in Chapter 9. The LET is proportional to
the charge and inversely proportional to the velocity (to some power) of the charged particle travel-
ing in the target. The energy transferred ionizes the material in the medium. The specific ioniza-
tion (SI) is the number of ion pairs produced per unit length as indicated in Figure 6.2 by the star
like (darker gray) explosions along the particle path. Higher LET particles produce ion pairs closer
together. The energy transferred, the LET will be related to SI × W (energy required/ion pair). A
characteristic distance of the DNA is on the order of nanometers. Indirect effects make up about
80% of the action for lower LET particles.
FIGURE 6.2 Interactions in and near DNA.
Some typical values of LET are

Particle LET
60Co
0.25 keV/µm
Alpha 250 keV/µm
Proton 1–30 keV/µm
Neutron 30 keV/µm
Carbon 40–100 keV/µm
After these effects to the cell, there are a number of pathways to cell inactivation. The cell could
basically enter a programmed death called apoptosis. It could die from necrosis or from a nutrient
deficiency called autophagy.
To damage unwanted cells using ionizing radiation, it is necessary to deposit the energy locally
near the critical structures of the unwanted cells. Choosing an appropriate particle that will create
a sufficient number of ionization pairs near the DNA will enhance the probability of cell death.
However, the cell can repair itself, depending upon the type of damage. Elements of this are referred
to as four Rs of radiotherapy and they include
• Repair of sublethal damage. Single strand breaks can be repaired.

• Repopulation by surviving cells. The surviving bad cells repopulate.
• Redistribution of cells throughout the division cycle. The sensitivity of a cell to radiation
depends on the biological phase of the cell’s survival cycle. Different cells are in different
phases of the cycle at any given time, so not all are affected in the same way at the same
time. One of the factors contributing to the sensitivity of cells to radiotherapy is the posi-
tion of a cell in its proliferation cycle:
• Mitosis – division takes place
• Synthesis – DNA is synthesized
• Reoxygenation of hypoxic cells. Oxygen is important for the chemical reactions.
Proliferation of cancerous cells takes place faster than the ability to generate blood vessels
for oxygen transport. Soon some cells get buried and don’t get enough oxygen to be radio-
sensitive to the indirect mechanisms.
7 Exponentials
7.1 e
The fields of beam physics and medical physics are steeped in the properties of exponentials. It is
useful to review some of the high-level properties. The exponential or Euler number (e) is given by,
n
1
e = lim  1 +  (7.1)
n→∞  n
Or it can be represented as e = ∑ ∞n = 0 (1/n!) = 2.718281… The functions ex and e−x are plotted in
Figure 7.1. e1 equals the value of e = 2.718281… and 1/e1 = 0.3678. This 1/e value is used frequently,
as frequently as 1/10 might be used. ex is sometimes written as exp(x). The plot of ex grows and its
rate of increase grows, well, exponentially. It has an interesting property in that
d x
e = ex (7.2)
dx
So, its derivative is equal to itself. This means that its slope at any given point is equal to its value
at that point. Yes this seems trivial, but it means that if a function increases or decreases at a rate
proportional to its present value, the function can be an exponential. Money might be the first thing
that comes to a nonphysicists mind in this respect.
FIGURE 7.1 Plot of e and 1/e.
Note that e2 is just e1 · e1 = e1+1. The natural logarithm ln is defined with respect to base e such that
ln ( e x ) = x (7.3)
The derivative is given by
d 1 d 1 d ( f ( x ))
ln ( x ) = ; ln ( f ( x )) = (7.4)
dx x dx f ( x ) dx
DOI: 10.1201/9781003123880-7 29
The exponential function ex can be expanded in a Taylor expansion, from Equation 7.1 as
∞
e =
x
∑
k =0
xk
k!
= 1+ x +
x2 x3 x4
2
+ +
6 24
+ (7.5)
7.2 DISTRIBUTIONS
There are many topics studied in the field of radiotherapy that are related to some sort of distri-
bution. It could be a distribution that characterizes the survival of cells in tissue, or it could be a
distribution of beam parameters in space. An understanding of the properties of these distributions
is helpful to determine important parameters which will yield a successful radiotherapy process.
7.2.1 Binomial Distribution

When the success or failure of an event is considered and the number of times this outcome is tested
is finite, the binomial distribution expresses the probability of the discrete, countable number of
successful results. The event could be flipping a coin to get a result of three heads out of ten flips,
rolling a pair of dice to get a snake eyes or it could be delivering dose to ten cells to get a result of
two cell deactivations, it either happened or it didn’t.
There are two parts to determining the probability of the number of successes (S) in a trial. If the
result is not a success, it is a failure (F). One part is the probability of the success of one possible way
the result can occur. The second is to determine the number of ways that it can occur. For example,
if the chances of success are 50% for an event and it is of interest to know the chances of obtaining
a result of three successes in six tries consider the ways this can occur. One way is if there are three
successive successes: SSSFFF. The likelihood is the product of the probabilities (p) of each event or
p(S)*p(S)*p(S)*p(F)*p(F)*p(F) or 1.56%. It is convenient to define p to be the probability of a suc-
cess and q = 1 − p to be the probability of a failure, then the probability of this result is p*p*p*q*q*q.
Thinking of it this way, then after the first three successes, each with probability p, the subsequent
three events are characterized by the probability that it will fail or q.
However, this is not the only way three successes can be achieved. The number of different ways
that n things can be arranged or the number of permutation is n! For example, there are 6 (3!) per-
mutations of ABC; they are ABC, ACB, BAC, BCA, CBA and CAB. Finally, the number of ways of
selecting m distinct combinations of n objects is the binomial coefficient
n!  n 
≡   ≡ n Cm (7.6)
m !( n − m )!  m 
(C stands for combinations in this context.) For example, the number of combinations of two of ABC
is AB, AC, BC. Calculating this from the binomial coefficient gives 3!/(2! * 1!) = 3.
Three parameters have been defined:
n = number of times the attempt is conducted (trials) or number of things examined

m = number of successes during those n trials or number of specific things found
p = the probability of a specific outcome for each trial
It is desired to know the probability of the occurrence of a number of events. There are four main
conditions which must be satisfied if that probability is to be given by a binomial distribution. These are:
1. Binary = Each result is either a success or failure

2. Independent = Each trial is independent. No result of any trial depends upon the result of
a previous or subsequent trial
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never closed, or had been opened, and there in their sarcophagi lay
the dead.
In a past age some of the granite coverings and coffin-lids had
been removed, but the mummies remained inviolate, even their
golden ornaments were not disturbed. Those of one young queen, or
rather chieftainess, who had died a few years before the birth of
Christ were indeed of remarkable beauty and great value,
comprising a crown of gold filagree and enamelled flowers of
marvellous workmanship, inlaid pectoral and bracelets and a sceptre
of gold surmounted by a crystal symbol of the sun. Mea took them
from the body and arrayed herself in them and stood before Rupert a
queen of Egypt, as once he had seen her stand in the sanctuary at
Abu-Simbel. Very wonderful she looked thus with the lamp-light
shining upon her in that awesome, silent place.
“What are you doing?” he asked, for notwithstanding the bizarre
beauty of her decorations, it jarred upon him to see her ornamented
with these insignia of death.
“I try them on, Rupert Bey,” she answered. “As we cannot make
such things now I will borrow them from the lady, my long-ago
grandmother, to be buried in. Come here; I show you my tomb.”
Then she led the way past certain built-up chambers in which, she
informed him, her immediate predecessors lay uncoffined, to a
recess where was a magnificent sarcophagus of alabaster. It was
graved about with the usual texts from the Book of the Dead, but had
several peculiarities. Thus in its great interior were places for two
bodies with a little ridge of alabaster left to separate them. It was
quite empty, the massive lid which stood by its side never having
been put on. Also the spaces for the name, or names, of its
occupants were left blank, showing that those for whom it was
prepared rested elsewhere.
“Where are they?” asked Rupert, as with the help of Mea and his
crutch he scrambled down from the pediment of the tomb.
“Don’t know,” she answered, “perhaps die somewhere else, or
killed by enemy; perhaps quarrel, and no wish to be buried together.
I take their house when my time comes; just fit me.”
“Then you mean your husband to lie there too?” blurted out
Rupert, without thinking.
Holding the lamp in her hand she turned and looked at him with
steady eyes.
“Understand, Rupert Bey,” she said, “I have no husband, never—
never. All day I work alone, when night come I sleep alone. Then my
people build up this place—all, all, for I the last and nobody ever
come in here any more. Yes, build it up with stone of the temple and
make it solid like the mountain, for I wish to sleep long and quiet.”
Such were the oasis Tama and its antiquities. Of its people there is
little to say, save that they were grave in demeanour, rather light in
colour and handsome in appearance, especially the women, looking
much as the last descendants of an ancient and high-bred race
might be expected to look. The men, as we have seen, were brave
enough in war, suspicious and exclusive also, but indolent at home,
doing no more work than was necessary, and for the most part
lacking the energy to trade. Their customs as regards marriage and
other matters were those common to Nubia and the Soudan, but
although they talked of Allah they were not Mahommedans, and if
they worshipped anything, it was God as symbolised by the sun.
Indeed this was all that remained of their ancient faith, with the
exception of certain feasts and days of mourning, whereof they had
long forgotten the origin. Only a few of the old women before a
marriage or a burial, or any other event of importance, would
occasionally creep down to the vault and pour a libation to the statue
of Osiris that wore the crown and feathers of Amen-Ra, as, in an
hour of danger, Bakhita had made Mea do at Abu-Simbel.
This survival was interesting, but Rupert was never able to
discover whether it had descended from the ancient days, or
whether they had learnt the practice from the sculptures on the
temple and the paintings in the vault, which showed the departed
rulers and their wives and attendants pouring such libations before
this very statue. At least, of the old religion nothing else remained,
nor could anyone in Tama read the hieroglyphics. It was her desire to
acquire this and other learning, and to become acquainted with
those men and the wonderful outside world, whereof rumours had
reached her in her isolated solitude, that had caused Mea to disguise
herself and spend two years at the school at Luxor. Here, although,
as she found to her disappointment, they did not teach hieroglyphics,
she had accumulated a considerable quantity of miscellaneous
knowledge of men and things, including a superficial acquaintance
with the English tongue, in which she loved to talk.
Now she insisted upon continuing her education under Rupert’s
guidance, and as they had only one book, the instruction took the
form of lectures upon history, literature, art, and everything else
under the sun with which he had the slightest acquaintance. It was a
strange sight to see them in one of the big rooms of her house, Mea
seated at a little table and Rupert limping to and fro upon his crutch,
and holding forth on all things, human and Divine, such as
Egyptology—of which he really knew something; modern political
history, especially that of Africa, and religion. Indeed, the last played
a large part in their studies, for as it happened among the few
belongings that were saved from the saddle-bags of his camel was
Rupert’s Bible, that same skin-bound volume which had excited
Edith’s wonder and interest. Therefore it was out of this Bible that he
made her read to him, with the result that she learned from it more
than the letter. As he intended that she should, soon she began to
appreciate the spirit also, and in its light to understand much that had
puzzled her in Rupert’s conduct towards herself and others. But the
knowledge did not teach her to love him less, only perhaps she
honoured him the more.
So the weeks passed on, and strange as were the conditions of
his life, not altogether unhappily for Rupert. As yet it was impossible
for him to leave the oasis for the reasons that have been given, and
sometimes with a sudden sense of shame, he awoke to the fact that
this detention was no longer the agony to him that it had been at
first; that now indeed he could endure it with patience. Of course the
truth was that we are all of us very much the creatures of our
immediate surroundings, and that the atmosphere of this peaceful
desert home had crept into his being, bringing with it rest, if not
content. He had suffered so much in mind and body, and now he
was not called upon to suffer. So skilful was she in her dealings with
him, so well did she veil her heart in its wrappings of courtesy and
friendship, that he ceased even, or at any rate to a great extent, to
be anxious about Mea.
He tried to forget that passionate scene, and when he did think of
it his modesty prompted him to believe that it really meant nothing.
Eastern women were, he knew, very impulsive, also very changeful.
Probably what had moved her, although at the time she did not know
it, was not devotion to a shattered hulk of a man like himself, but as
she had said at the beginning, pity for his sad state of which
indirectly she was the cause.
Al least he hoped that it was so, and what we hope earnestly in
time we may come to believe. So that trouble was smoothed away,
or at any rate remained in abeyance.
For the rest those palms and mountain-tops, those bubbling
waters and green fields, that solemn, ruined temple and those
towering pylons, were better than the parks and streets of London, or
that hateful habitation in Grosvenor Square where Lord Devene leant
against his haunted marble mantel-piece and mocked. Indeed, had it
not been for Edith and his mother, Rupert would, he felt, be content,
now that his career had gone, to renounce the world and live in
Tama all his days. But these two—the wife who must think herself a
widow, and the mother who believed herself sonless, he longed
ceaselessly to see again. For their sakes, day by day he watched for
an opportunity of escape.
At length it came.
“Rupert Bey,” said Mea quietly to him one morning in Arabic as
they sat down to their usual lesson, “I have good news for you. By
this time to-morrow you may be gone from here,” and whilst
pretending to look down at the parchment upon which she was
writing with a reed pen, as her forefathers might have done twenty
centuries before—for paper was scarce with them—she watched his
face from beneath her long lashes.
The intelligence stunned him a little, preventing—perhaps
fortunately—any outbreak of exuberant joy. Indeed, he only
answered in the words of the Arabic proverb:
“After calm, storm; after peace, war,” and the reply seemed to
satisfy Mea, although she knew that this proverb had an end to it
“after death, paradise—or hell.”
“How, Mea?” he asked presently.
“A big caravan, too strong to be attacked, is going to cross the Nile
above Wady-Halfa and pass through the Nubian desert to the shores
of the Red Sea beyond the country that is held by Osman Digna. Its
chief, who is known to our people, and a true man, makes the
pilgrimage to Mecca. I have sent messengers to him. He is willing
that you should accompany him, only you must not say who you are,
and if they meet any white men you must promise not to talk to them.
Otherwise, you may bring him into trouble for the befriending of a
Christian.”
“I will promise that,” answered Rupert.
“Good! Then you leave here to-morrow morning at the dawn. Now,
let us go on with the lesson; it is my last.”
That lesson proved a very desultory performance; indeed, it
consisted chiefly of a compilation by Rupert of lists of books, which
he instructed Mea she was to send to Egypt to buy, as soon as there
was an opportunity, in order that she might continue her education
by herself. But Mea seemed to have lost all interest in the future
improvement of her mind.
What was the good of learning, she asked, if there was nobody to
talk to of what she had learned? Bakhita did not care for these
things, and the others had never heard of them.
Still she took the lists and said she would send for the books when
she could, that was, after the country grew quiet.
The rest of that miserable day went by somehow. There were
meals to eat as usual; also Rupert’s dromedary had to be got up,
and a store of food made ready for his journey. Mea wanted him to
take money, of which she had a certain amount hidden away—
several thousand pounds indeed—the products of her share of sales
of horses and corn which the tribe occasionally effected with
travelling merchants, who bought from them cheap and sold to the
Egyptian Government, or others, dear. But this he would not touch,
nor did he need to do so, for in his clothes when he was captured
were sewn about a hundred pounds, some in gold and some in
bank-notes, which he thought would be sufficient to take him to
England.
It was night. All was prepared. Rupert had said his farewells to the
emirs and chief men, who seemed very sorry that he was going. Mea
had vanished somewhere, and he did not know whether he would
see her again before he started at the dawn. The moon shone
brightly, and accompanied by the native dog that had led him when
he was blind, and having become attached to him, scenting
separation with the strange instinct of its race, refused to leave his
side that day, Rupert took his crutch and walked through the pylon of
the temple, partly in the hope that he might meet Mea, and partly to
see it once more at the time of full moon, when its ruin looked most
beautiful.
Through the hypostyle hall he went where owls flitted among the
great columns, till he came to the entrance of the vast crypt, a broad
rock-slope, down which in old days the sarcophagi were dragged.
Here he stopped, seating himself upon the head of a fallen statue,
and fell into a reverie, from which he was roused by the fidgeting and
low growlings of the dog, that ran down the slope and returned again
as though he wished to call his attention to something below.
At length his curiosity was excited, and led by the dog, Rupert
descended the long slope at the foot of which lay the underground
pool of water. Before he reached its end he saw a light, and limping
on quietly, perceived by its rays Bakhita and Mea, the former
bending over the pool, and the latter wrapped in a dark cloak, seated
native fashion at its edge. Guessing that the old gipsy was
celebrating another of her ancient ceremonies, he motioned the dog
to heel, stood still and watched.
Presently he saw her thrust out from the side of the pool a boat
about as large as that which boys sail upon the waters of the London
parks. It was built upon the model of the ancient Egyptian funerary
barges with a half deck forward, upon which lay something that
looked like a little mummy. Also, it had a single sail set. Bakhita gave
it a strong push, so that it floated out into the middle of the pool,
which was of the size of a large pond where, the momentum being
exhausted, it lay idly. Now the old woman stretched out a wand she
held and uttered a kind of invocation, which, so far as he could hear
and understand it, ran:
“Boat, boat, thou that bearest what was his, do my bidding. Sail
north, sail south, sail east, sail west, sail where his feet shall turn,
and where his feet shall bide, there stay. Boat, boat, let his Double
set thy sail. Boat, boat, let his Spirit breathe into thy sail. Boat, boat,
in the name of Ra, lord of life, in the name of Osiris, lord of death, I
bid thee bring that which was his, to north, south, east, or west,
where he shall bide at last. Boat, boat, obey.” *
* The Double and the Spirit here mentioned were doubtless those
constituent parts of the human entity which were known
respectively to the old Egyptians as the Ka (the Double), and the
Khu (the Soul itself). Of these, some traditional knowledge might
very well have descended to Bakhita.
She ceased and watched a little lamp which burnt upon the prow
of the boat, in front of the object that looked like a toy mummy. Mea
also rose and watched, while out of the darkness Rupert and the dog
watched too. For a little while the boat remained still, then one of the
numerous draughts that blew about these caverns seemed to catch
its sail, and slowly it drew away across the water.
“It goes west,” whispered Mea.
“Aye,” answered Bakhita, “west as he does. But will it bide in the
west?”
“I pray not,” answered Mea, “since ever from of old the west has
been the land of death, and therefore to the west of these waters lie
the sepulchres, and where the sun sets beyond the west bank of the
Nile, there for thousands of years our people laid their dead. Nay,
boat, tarry not in the west where Osiris rules, the cold and sorrowful
west. Return, return to the House of Ra, and in his light abide.”
Thus she murmured on, like one who makes a song to herself in
the Eastern fashion, all the while intently watching the little lamp that
showed the position of the boat. Having reached the western edge of
the pool, it seemed inclined to remain there, whereon Mea, turning to
Bakhita, began to scold her, asking her why she had brought her
there to see this childish play, and whether she thought that she,
Mea, who had been educated at Luxor and received many lessons
from the Bey, believed in her silly magic, or that a toy boat, even
though it did carry a man’s foot made up like a mummy, could
possibly tell whither he would wander.
“If the boat sails right, then you will believe; if it sails wrong, then
you will not believe. That I expected, and it is best,” answered
Bakhita drily, and at that moment something happened to the little
lamp that stood before the mummy foot, for suddenly it went out.
Now Mea grew positively angry, and spoke sharp words to Bakhita
as to her methods of divination and the benighted and primitive
condition of her intelligence in general.
“Were I to accept the augury of your boat,” she said, “I must be
sure not only that he will stay in the west, but that he will die there,
for look, the light is out.”
“Other things die beside men’s bodies,” answered Bakhita, in her
brief fashion; “their hopes, or beliefs, or perhaps their good luck—
who can say?”
As she spoke, suddenly out from the darkness of the pool into the
ring of light cast by the lamp which Bakhita bore, that fairy boat came
gliding. The gust of wind blowing down the western sepulchres
beyond the pool, which extinguished its lamp, had also caught its sail
and brought it back, half filled with water shipped in turning; brought
it back swiftly, but sailing straight to where Mea knelt upon the edge
of the pool. She saw it, and with a little cry of joy, bent herself over
the water, and stretching out her rounded arms, caught the boat just
before it sank, and hugged it to her breast.
“Put the thing down,” said Bakhita. “You don’t believe in it, and it is
wet and will spoil your robe. Nay, the Bey’s foot is mine, not yours. I
brought it from the Wells.”
Then they began to quarrel over this poor mummied relic of which
Rupert thought that he had seen the last many a day before, while
he took an opportunity to beat his retreat. Bakhita and her ancient
spells were, as usual, interesting, though when they involved a lost
fragment of himself they became somewhat gruesome. But in such
things he had no belief whatsoever; they only attracted him as
historical, or rather as spiritual survivals. What moved him about the
matter was Mea’s part in it, revealing, as it did, that her interest in his
future had in no way abated. Indeed, he felt that it would be long
before he was able to forget the touching sight of this wayward and
beautiful girl, this desert-bred daughter of kings, snatching the
sinking boat and its grizzly burden from the water and pressing them
to her breast as though they were a living child. Meanwhile, the
accident that he had seen it did not make this farewell less difficult.
When at length he reached the house—for amongst the fallen
stones of the temple his progress with a crutch was slow—Rupert
sat down upon its steps, feeling sure that Mea would wish to see
him, and that it would be well to get that parting over. Presently the
mongrel at his side began to bark, and next minute he saw her
walking slowly up the path towards him, her cloak open and the
breast of her robe still wet where she had pressed the dripping boat
against it. He struggled from the step to meet her.
“Sit, Rupert Bey,” she said; “sit. Why trouble you to rise for me?”
“I cannot sit while you stand,” he answered.
“Then I sit also, on the other side of the dog. He look like the god
on the wall, does he not, what you call him—Anubis, brother of
Osiris? No, don’t growl at me, Anubis; I no hurt your master, you
nasty little god of the dead.”
“Where have you been, and why is your dress wet?” asked
Rupert.
“Ask Anubis here, he wise, knows as much as his master. I been
to the burying-place and lean over holy water to look if I grow more
ugly than usual.”
“Stuff!” answered Rupert.
“You no believe me? Well, then, perhaps I thirsty and drink water.
Much weep make me thirsty. No believe still? Then perhaps I look in
water and see pictures there.”
“What pictures can you see in that dark place?”
“Oh, plenty, dark no matter. See things inside, like you when you
blind. I tell you what I see; I see you come back here, and so I weep
no more. I—I—happy. Make that dog go the other side, he want to
bite me now, he jealous because you look at me, not him.”
Accordingly the protesting Anubis was rearranged, and continued
his snarlings and grumblings from a safer distance.
“Some more of old Bakhita’s nonsense, I suppose,” said Rupert. “I
thought that you had given up believing in her myths and omens.”
“What mean myths and omens? No matter; Bakhita old fool, gods
old stones, believe in none of them. You say it, so all right. Believe in
you, and me—inside, what my heart tell me. My heart tell me you
come back. That why I happy.”
“Then I am afraid, Mea, that your heart knows more than I do.”
“Yes,” she answered, “think more; feel more, so know more. That
all right; what do you expect?” Then suddenly dropping her jerky and
peculiar English, Mea addressed him in her solemn and native
Arabic. “Hark you, Rupert, guest of my home, guest of my heart,
preserver of my body, who shed your blood for me. You think me
foolish, one who tries to warm her hands at the fires of the marsh,
one who plucks flowers that fade, and believes them immortal stars
fallen to deck her breast and hair. Yet she finds warmth in the marsh
fire, and in the dead flower’s heart a star. I believe that you will come
back, why or how it matters not, but to make sure you shall swear an
oath to me, you shall swear it by the name of your Jesus, for then it
will not be broke.”
“What oath?” asked Rupert anxiously.
“This: Sometimes lamps go out, and where we thought light was
there is great blackness. Sometimes hopes fail, and death stands
where life should have been. This may chance to you, Rupert Bey,
yonder in the cold, western land of the setting sun.”
“Do you mean that I shall find my wife dead?” he asked, with a
quiver in his voice. “Is that the picture you saw in your pool?”
“Nay; I saw it not; I do not know. I think she lives and is well. But
there are other sorts of death. Faith can die, hope can die, love can
die. I tell you I know not, I know nothing; I have no magic; I believe in
no divination. I only believe in what my heart tells me, and perchance
it tells me wrong. Still I ask you to swear this. If things should so
befall that there is nothing more to keep you in the West, if you
should need to find new faith, new hope, new love, then that you will
come back to Tama and to me. Swear it now by the name of your
God, Jesus; so I may be sure that you will keep the oath.”
“I do not swear by that name,” he answered. “Moreover why
should I swear at all?”
“For my sake, Rupert Bey, you will. Hear me and decide. I tell you
that if you do not come back, then I die. I do not ask to be your wife,
that does not matter to me, but I ask to see you day by day. If I do
not see you, then I die.”
“But, Mea,” he said, “it may be impossible. You know why.”
“If it is impossible, so be it, I die. Then it is better that I die.
Perhaps I kill myself, I do not know, at any rate I go away. I ask not
that you should swear to come, if it should make you break your oath
to others, only if there are no more oaths to keep. Now choose,
Rupert Bey. Give me life or give me death, as you desire. Make your
decree. I shall not be angry. Declare your will that your servant may
obey,” and she rose and stood before him with bent head and hands
humbly crossed upon her breast.
He looked at her. There could be no doubt she was in earnest.
Mea meant what she said, and she said that if he did not gratify this
strange wish of hers, and refused to give her any hope of his return,
she would die, or at least so he understood her; and was certain that
if she had the hope, she would not die and bring her blood upon his
head. Rupert looked at her again, standing there in the moonlight
like some perfect statue of humility, and his spirit melted within him,
a blush of shame spread itself over his scarred and rugged features,
shame that this loyal-hearted and most honoured woman should
thus lay her soul naked before him, saying that it must starve if he
would not feed it with the crumb of comfort that it desired. Then he
hesitated no longer.
“Mea,” he said, in the kind and pleasant voice that was perhaps
his greatest charm—“Mea, my law says: ‘Swear not at all’; I read it to
you the other day. Now, Mea, will my word do instead?”
“My lord’s word is as other men’s oaths,” she answered, lifting her
humble eyes a little.
Then he bent forward, resting on his knee, not as an act of
adoration, but because it was difficult to him to rise without
assistance, and stretching out his hand, took her crossed hands from
her breast, and bowing himself, pressed them against his forehead,
thus—as she, an Eastern, knew well—prostrating himself before her,
making the ancient obeisance that a man can only make with honour
to his liege sovereign, or to one who has conquered him.
“My lady Tama,” he went on, “after one other my life is yours, for
you gave it back to me, and after her and my mother there lives no
woman whom I honour half so much as you, my lady and my friend.
Therefore, Mea, since you wish it, and think that it would make you
happier, should I perchance be left alone—which God forbid!—I
promise you that I will come to you and spend my life with you until
you weary of me—not as a husband, which you say you do not
desire, which also might be impossible, but as a brother and a friend.
Is that what you wish me to say?” and he loosed her hand, bowed to
her once more in the Eastern fashion, with his own outstretched, so
that his fingers just touched her feet, and raised himself to the step
again.
“Oh!” she answered, in deep and thrilling tones, “all, all! More, by
far, than I had hoped. Now I will not die; I will live! Yes, I will keep my
life like a jewel beyond price, because I shall know, even if you do
not come, that you may come some time, and that if you never
come, yet you would have come if you could—that the marsh-light is
true fire, and that the flower will one day be a star. For soon or late
we shall meet again, Rupert Bey! Only, you should not have
prostrated yourself to me, who am all unworthy. Well, I will work, I will
learn, I will become worthy. A gift, my lord! Leave me that holy book
of yours, that I may study it and believe what you believe.”
He limped into the house and brought back the tattered old Bible
bound in buckskin.
“You couldn’t have asked for anything that I value more, Mea,” he
said, “for I have had that book since I was a child, and for that
reason I am very glad to give it to you. Only read it for its own sake—
not for mine—and believe for Truth’s sake, not because it would
please me.”
“I hear and I obey,” she said, as she took the book and thrust it
into the bosom of her loose robe.
Then for a moment they stood facing each other in silence, till at
length, perhaps because she was unable to speak, she lifted her
hands, held them over him as though in blessing, then turned and
glided away into the shadows of the night.
He did not see her any more.
CHAPTER XVI.
MEANWHILE
It was the last day of the old year when, had there been anyone to
take interest in her proceedings among so many finer vessels going
to or returning from their business on the great waters, a black and
dirty tramp steamer, whose trade it was to carry coals to the East,
might have been seen creeping up the Thames with the tide. A light
but greasy fog hung over the face of the river, making navigation
difficult, and blurring the outlines of the buildings on its bank, and
through it the sound of the church bells—for it was Sunday—floated
heavily, as though their clappers had been muffled in honour of the
decease of one of the great ones of the earth.
In his cabin—for after the suns of the Soudan the winter wind was
too cold to face—sat Rupert Ullershaw, dressed in a mustard-
coloured suit of reach-me-downs, somewhat too small for him, and
of a peculiarly hideous cut and pattern, which he had purchased
from a sailor. Physically he was in good health, but his mental
condition may best be described as one of nervous irritability born of
weeks and months of suspense. What news awaited him on his
arrival home, he wondered, and how would he, a discredited and
mutilated cripple, be received?
That he was discredited he knew already, for he had found an old
paper on board the ship, in which, on looking at it, his own name had
leapt to his eye. Someone had asked a question in Parliament
concerning him and his mission—why it had been sent, what were
the facts of the rumours of its annihilation, whether it was true that
this disaster had been brought about through the envoy, Lieutenant-
Colonel Ullershaw, C.B., having mixed himself up in tribal quarrels
over a native woman, and what was the pecuniary loss involved to
the country? Then followed the answer of the Secretary of State, the
man who had pressed him to go on the grounds of duty and
patriotism. It stated that Colonel Ullershaw had been despatched to
carry out certain confidential negotiations with a number of sheiks on
the borders of the Soudan. That according to the report received
from the Egyptian authorities, a native sergeant named Abdullah,
who accompanied him, had arrived at Cairo and informed them that
all the members of the mission, who were disguised as merchants,
had been attacked by a petty chief called Ibrahim and destroyed,
Abdullah alone escaping. That it appeared from this survivor’s
evidence that the attack was not political, but had its origin in Colonel
Ullershaw having unfortunately tried to protect two native women
who were travelling with him, one of whom, stated to be a young
person of some rank, was claimed by the sheik Ibrahim as a wife.
That the loss to the country, or rather to the Egyptian Government,
amounted to about two thousand pounds, of which one thousand
was in cash.
Arising out of this were other questions, evidently framed to annoy
the Government upon a small matter, such as: Was it true that
Colonel Ullershaw had been chosen over the heads of more suitable
persons, because his great family influence had been brought to
bear upon the War Office? To this the answer was that the deceased
officer’s record had been very distinguished, and he was chosen
because of his diplomatic experience, his knowledge of Arabic and
personal acquaintance with the sheiks, with whom it was necessary
to communicate: That, as the House would be aware, his family
influence as represented in that House, and, he might add, in
another place, was not likely to unduly influence Her Majesty’s
present advisers, of whom the gentlemen concerned were strong
and able opponents. (A laugh.)
The thirst for information not being yet appeased, an Irish member
asked whether it was true that a punitive expedition had been sent to
kill the chief whose wife Colonel Ullershaw had stolen—(laughter);
and whether the Government now regretted their choice of Colonel
Ullershaw as the head of this mission.
Answer: That such an expedition had been sent, but that it
appeared that Colonel Ullershaw and his party had made a very
gallant fight before they were overwhelmed, and that either he, or, as
was stated by some nomads, the lady, whom he had befriended,
with the help of her tribesmen had already killed the sheik Ibrahim
and most of his men, whose corpses had been seen by the nomads
hanging to some trees: That the Government admitted that their
choice had not been justified by events, but that he, the Secretary of
State, deprecated the casting of slurs upon very insufficient
information upon the memory of a brave and devoted servant of his
country—(hear, hear!)—whose mistakes, whatever they might have
been, seemed to have sprung from the exaggerated chivalry of his
nature. (A laugh.)
Another Irish member: Was it true that Colonel Ullershaw had
been married on the day he left England to enter upon this mission?
The Speaker: “Order, order. This House has nothing to do with the
domestic concerns of the late Colonel Ullershaw.”
The Honourable member apologised for his question, remarking
that his excuse for it must be that the country, or Egypt, had to pay in
lives and money for the domestic entanglements of Colonel
Ullershaw, in which he became involved among the desert sands.
(Much laughter and cries of order.) He wished to ask the Right
Honourable gentleman whether he was sure that the gallant Colonel
—(more laughter)—was really dead?
The Secretary of War: “I fear there is no doubt upon that point.”
The subject then dropped.
Turning over the paper in a dazed fashion—for the cruelty and

injustice of these questions and the insinuations so lightly made for
party purposes cut him to the heart—Rupert had come upon a sub-
leader which discussed the matter in a tone of solemn ignorance.
Being an Opposition organ, the leader-writer of the journal seemed
to assume that the facts were correctly stated, and that the
unfortunate officer concerned brought about the failure of the
mission and lost his own life by a course of action so foolish as to be
discreditable, in which, as it stated, “the ever-present hand of female
influence can unfortunately be traced.” It added that deeply as the
death of a man who had served his country well and gallantly in the
past was to be regretted, perhaps for Colonel Ullershaw it was the
best thing that could have happened, since it seemed probable that
in any event his career would have been at an end.
After reading this report and comment, Rupert’s common-sense
and knowledge of official ways assured him that, however unjustly,
he was in all probability a ruined man. On the charges about the lady
in the desert he might, it is true, be able to put a different
complexion, but it would be impossible for him to deny that the
unfortunate presence of Bakhita and Mea had been the immediate
cause of his disaster, or indeed that he had been spending several
months as their guest. Beyond these details, however, lay the
crushing fact that he who had been expected to succeed, had utterly
and completely failed, and by failing, exposed those who employed
him to sharp criticism and unpleasant insinuations. Lastly, the
circumstance that he was now a hopeless cripple would of course be
taken advantage of to dispense with his further services.
So convinced was he of the desperate nature of his plight that he
had not even attempted to offer any explanation to the Egyptian
Government, as he saw that his only chance lay in influencing those
at headquarters and persuading them to order a further local inquiry
in Egypt. Besides, he was anxious to get home, and knew that if he
had opened up the matter in Cairo, he would probably be detained
for months, and very possibly be put under arrest pending
investigations.
Rupert’s journey across the desert had been long, but unmarked
by any incident or danger, for they passed round Osman Digna’s
hordes and through country that was practically depopulated,
meeting but few natives and no white men. So far as Rupert was
concerned it was comfortable enough; since after the Arab caravan
had started from the neighbourhood of Tama, he found to his
surprise that Mea had provided him with a guard of twenty of her
best men, who brought with them a tent and ample provisions. He
ordered them to return, but they refused, saying that they had been
commanded by their lady to travel with him to the Red Sea as an
escort to the dog Anubis that had insisted upon following him from
the town, which dog they were charged to bring back safely when he
parted with it at the water. Then understanding what Mea meant by
this Eastern subterfuge about the dog and fearing to hurt her
feelings, should he insist, he suffered the men to come with him, with
the good result that he found himself regarded as a great personage
in the caravan.
At length they reached a little port on the Red Sea whence the
pilgrims to Mecca proposed to proceed by dhow to Suez, and, as it
chanced, found there this English collier that was taking in fresh
water. On her Rupert embarked with the pilgrims, passing himself off
as one of them, for the captain of the collier was glad to earn a little
by taking passengers. The last that he saw of the desert was his
Tama escort, who, having kissed his hand and made their dignified
farewells, were turning their camels’ heads homewards, the poor cur,
Anubis, notwithstanding his howls and struggles, being secured in a
basket which was fastened to the side of one of the said camels. No;
that was not quite the last, for as the boat rowed out to the steamer
which lay at a little distance, it passed a jutting spit of land that gave
shelter to the shallow harbour. Of a sudden from this promontory
there floated up a sound of wild, sad music, a music of pipes and
drums. Rupert recognised it at once; it was the same that he had
heard when he rode with Bakhita and Mea from Abu-Simbel, the
music of the Wandering Players, those marvellous men who refused
baksheesh.
As the morning mist lifted he saw them well, on the sandy beach
within twenty yards of the boat. There were the five muffled figures
squatted on the ground, three blowing at their pipes and two seated
opposite to them beating drums to time. As before they seemed to
take not the slightest notice of the passers-by, except that their
music grew wilder and more shrill. An English sailor in the boat
shouted to them to stop that funeral march and play something
funny, but they never lifted their heads, whereon, remarking that
theirs was a queer way to earn a living, caterwauling to the birds and
fishes, the sailor turned his attention to the tiller and thought no more
about them. But even on the ship their melancholy music could be
heard floating across the water, although the players themselves
were lost in the haze. Indeed, it was while Rupert read the report of
what had passed in the House of Commons in the old paper which
he found in the deck cabin, that its last wailing burst reached him
and slowly faded into silence.
At Suez the pilgrims left the steamer, but as she suited him very
well, and the fare demanded did not make any big hole in his £100,
he revealed himself as an Englishman and booked a passage on to
London. Now London was in sight, yonder it lay beneath that dark
mass of cloud, and—what would he find there? He had not
telegraphed from Suez or Port Said.
It was, he felt, impossible to explain matters in a cable, and what
could be the use, especially as then everything would get into the
Press? They thought him dead, or so he gathered from that paper,
therefore no one would incur extra suspense or sorrow by waiting for
a few more days, to find that he, or some of him, was still alive. He
longed to see his wife with a great longing; by day and by night he
thought of her, dreaming of the love and sympathy with which she
would greet him.
Yet at times doubts did cross his mind, for Edith loved success,
and he was now an utter failure, whose misfortunes must involve her
also. Could he be the same Rupert Ullershaw who had left Charing
Cross railway station nine months before, prosperous, distinguished,
chosen for an important mission, with a great career before him?
Undoubtedly he was, but all these things had left him; like his body
his future was utterly marred, and his present seemed almost
shameful. Nothing remained to him now except his wife’s love.
He comforted himself. She would not withhold that who had taken
him for better or worse; indeed it was the nature of women to show
unsuspected qualities when trouble overtook those who were dear to
them. No; upon this point he need not torment himself, but there
were others.
Was he to tell Edith the dreadful secret of her birth which had
haunted him like a nightmare all these weary months? Sooner or
later he supposed that it must be done. And must he meet Lord
Devene, and if so, what was he to say when they did meet? Then
Edith would want to know the truth of this story of the lady in the
desert, which, of course, she had a right to learn in its every detail.
There was nothing in it. Mea was no more than a dear friend to him;
indeed he had thought of her but little lately, whose mind was so
preoccupied with other matters. Yet he felt that the tale of their
relationship, told exactly as it occurred, and he could repeat it in no
other way, might be open to misinterpretation, as the facts of his
escort of her and her aunt across the desert had been already.
Well, she would have to take his word for it, and even if she did
not estimate that quite as high as Mea had done, at least she knew
that he was no teller of lies. Then after these difficulties were
overcome, how was he to live? He had saved a little money, and
perhaps as a wounded man they might give him a small pension, out
of which his heavy insurance would have to be paid, if indeed it did
not absorb it all. There remained her father’s—he winced as the
word came into his mind—settlement upon Edith, but that income,
personally, he would rather starve than touch. Still his wife must be
supported in a way commensurate with her position. This outlook,
too, was so black that he abandoned its consideration and fell to
thinking of the joy of his meeting with his mother.
Here at least there were no ifs or buts. She would understand, she
would console; his misfortunes would only make him dearer to her.
For the rest, sufficient to the day was its evil—the morrow must take
care of itself. It was indeed sufficient.
Now while the old tramp lumbers up the Thames through the grey
December mist and sleet, let us turn for a few minutes to the
fortunes of some of the other personages in this history.
After her husband’s departure, Edith returned to live with Mrs.
Ullershaw, which was an inexpensive arrangement, and, as she
explained to Dick, the right kind of thing to do. Several letters arrived
from Rupert, the last written at Abu-Simbel the night before he began
his fatal journey, and some were sent in reply which he never
received. Then came the long silence, and after it the awful, sudden
catastrophe of which they learned first from a Cairo telegram in an
evening paper. Rupert was dead, and she, Edith, who had never

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Particle Therapy Technology for Safe

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Cryptocurrency: Concepts, Technology, and Applications

Cryptocurrency Concepts, Technology, and Applications

First Edition published 2022

and by CRC Press

© 2022 Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, LLC

ISBN: 978-0-367-64014-9 (hbk)

Typeset in Times LT Std

BK-TandF-FLANZ_9780367640149-211314-FM.indd 4 13/12/21 12:34 PM

Fun with Family helps to keep Physics Fun!

Cover Art: Heaven’s Charged Particle Scanning System

Chapter 2 Evolution of Medical Particles......................................................................................3

Chapter 3 A Personal Historical Perspective............................................................................... 13

Chapter 4 Flow of Requirements................................................................................................. 17

Chapter 5 External Beam Systems.............................................................................................. 21

Chapter 6 How to Damage Unwanted Cells................................................................................25

Chapter 8 Relativistic Dynamics................................................................................................. 55

Chapter 9 Charged Particle Interactions in Matter...................................................................... 61

Chapter 10 Review of Charged Particle Motion............................................................................ 83

Chapter 11 Clinical Perspective of Charged Particle Therapy Beams........................................ 121

Chapter 12 Three-Dimensional Dose Conformation................................................................... 145

Chapter 13 Accelerator Systems..................................................................................................207

13.3.3.4 Time Dependence........................................................ 219

Chapter 14 Gantries..................................................................................................................... 255

14.6.2 The Corkscrew Gantry.................................................................... 270

Chapter 15 Safety in Radiotherapy.............................................................................................. 287

Chapter 16 Sensitivities and Tolerances: Scattering.................................................................... 327

Chapter 17 From Clinical to Technical Tolerances: Scanning.................................................... 335

Chapter 18 Afterword.................................................................................................................. 357

FIGURE 2.1 US population density map.

FIGURE 2.2 North American particle therapy facilities.

FIGURE 2.3 World particle therapy facilities.

FIGURE 2.4 Particle therapy number history.

FIGURE 2.5 Distribution of particle therapy.

FIGURE 3.1 Author’s mentor tree.

4.1 DIRECT REQUIREMENTS

• Deliver the required dose

FIGURE 4.1 Flow of requirements.

FIGURE 4.2 Parameter dependencies.

4.2 DEVELOPMENTAL REQUIREMENTS

The key goals of radiotherapy are to

• Deliver the required dose (including the required overall dose)

These components can be organized as in Figure 5.1.

FIGURE 5.1 Parts of a particle therapy system.

FIGURE 5.2 Layout of a cyclotron-based particle therapy system.

FIGURE 5.3 Target planes.

• Therefore, converting this energy into calories, 5 J/kg = 5/4.18 cal/kg.

FIGURE 6.1 Types of DNA damage.

6.1 DIRECT EFFECTS

Complex cell structure:

6.2 INDIRECT EFFECTS

or H 2 O + energy → H 2 O* → H·+·OH, (6.3)

FIGURE 6.2 Interactions in and near DNA.

Some typical values of LET are

• Repair of sublethal damage. Single strand breaks can be repaired.