731

X-Ray Gogs: Preliminary Evaluation of a“New” Imaging Modality

David K. Edwards 1111

Departments of Radiology and Pediatrics, Uni-versity of California at San Diego Medical Center,225 Dickinson St., San Diego, CA 92103. Addressreprint requests to D. K. Edwards Ill.

AJR 150:731-734, AprIl 19880361 -‘803X/88/1 504-0731© American Roentgen Ray Society

“X-Ray Gogs,” which apparently reveal internal anatomy without radiation, uftrasound,or magnetic fields, were compared with conventional imaging modalities in evaluatinga variety of pediatric conditions. Conventional techniques were preferable in terms ofdiagnostic accuracy and image quality, and are thus recommended in most settings.Because of low cost and lack of ionizing radiation, “X-Ray Gogs” are recommended incases where radiography is not indicated, or where the results of radiographic studywill not influence patient management, or where the diagnosis has already beenestablished by other means.

X-RAY GOGS. You saw these advertised in comic books as a child. And youwanted them with all your heart. And your parents objected. And you yielded.And since then life has not been very happy for you, has it? We offer a secondchance to buy, own and operate the famous X-ray glasses. According to thepackage, it is: the “scientific marvel of the century.” Not sold to communistcountries on the restricted list that also prohibits sales of Cray Supercompu-ters. $1 .25 each.

Quoted with permission from [1]

In this age of rapid advances in imaging techniques, it was mildly surprising toread the above advertisement and to realize that X-Ray Gogs (XRG), which havebeen available to the lay public for many years, have evidently not been examinedin medical context [2]. Because of parental skepticism and parsimony, the authornever owned XRG, and indeed life was not riotously happy thereafter. However, achildhood friend with less frugal parents recalls that XRG permitted visualization ofnot only digital bones but also the lead in a wooden pencil (Bobby “Bubba” Young,personal communication).

The intent of this preliminary study was to compare XRG with conventionalimaging modalities in a variety of clinical pediatric settings.

Materials and Methods

The XRG as received from the vendor (Archie McPhee & Co., Seattle, WA) consisted ofplastic frames with cardboard inserts containing 5-mm openings in which a red, translucent,striated material acted as a lens (Fig. 1). The striated material proved to be part of a redfeather [3]. To permit a correct interpupillary distance and to compensate for myopia, Iremoved the cardboard inserts and affixed them to prescription spectacles (Fig. 2).

A miscellaneous variety of pediatric sonographic (n = 30) and radiographic (n = 97)examinations (list available on persuasive request) were performed with simultaneous or near-simultaneous XRG observation. The bright light required by the XRG studies was intermittentlyturned on and offduring fluoroscopic procedures.

The Human Subjects Committee responded to routine petition in an uncouth, jocularmanner that was interpreted as approval. Because of the benign nature of XRG studies,informed consent was considered implicit. Pediatric patients (age, 1 day to 10 years) wereemployed both because of the author’s area of specialization and because adults, encoun-tered in hallways, responded adversely to the examiner’s appearance (Fig. 2), whereas

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Fig. 3.-Three of the author’s fingers viewed through X-Ray Gogs.

732 EDWARDS AJR:150, April 1988

Fig. 1.-Obverse of X-Ray Gogs andpackage label, photographed on cor-duroy (5.5 ridges/cm). Reverse ofpackage label (not shown) contains in-structions and faintly distasteful insin-uations about seeing through clothing.

Fig. 2.-X-Ray Gogs modified foruse with prescription lenses.

children seemed intrigued, and infants oblivious. The passive voicewas used wherever possible in this report.

The obviously harmless character of XRG allowed bypassing te-dious laboratory investigation involving rodents and other vermin.Following the model of the similarly seminal early communications ofWilhelm Roentgen [4], this study was not cluttered with annoyinggibberish about line-pairs, ROC curves, sensitivity/specificity, andsimilar incomprehensibilities.

Results

Preliminary Evaluations

When used as instructed (i.e., viewing structures against astrong light), the XRG displayed the soft tissues of the fingersin a pleasing pink, with darker central regions that were surelyeither bones or something else (Fig. 3). Similarly, a woodenpencil thus viewed revealed pink edges and a dark centralline that suggested the pencil’s graphite core. The potential,hinted by the manufacturer, of seeing through clothing wasexplored with selected female staff members to the point ofeyestrain, without success. Continual wearing of the XRGoffered the advantage that the eyes remained dark-adapted;however, it was difficult to find one’s way about the depart-ment in what seemed a dense red fog, hounded by the jeersof one’s colleagues.

Comparative Study

The results comparing XRG and conventional studies arepresented in Table 1 . Conventional studies were notablysuperior in furnishing the correct diagnosis. The XRG studiesprovided the correct diagnosis only in those instances whenthe conventional study also revealed no abnormality. Animportant reason for this disparity appeared to be imagequality, which was invariably inferior with XRG. Indeed, on nooccasions were axial skeletal structures, soft tissue-gas in-terfaces, or administered contrast materials discernible withXRG; all that was seen was a pink, patient-shaped blur.

On the other hand, XRG was superior in terms of ease ofexamination (one had only to look at the patient with a brightlight in the background), cost (negligible), and radiation dose(nil). With these advantages in mind, the cases were reviewedretrospectively to define the actual benefit afforded the patientby the imaging study; 13 cases (1 0%) were found in whichthe benefit of the XRG study was at least the same as thatof the conventional study. These were cases in which at leastone of the following pertained: (1) the radiographic study wasnot indicated; (2) no change in patient management wouldoccur whatever the results of the radiographic study; or (3)the diagnosis was already firmly established by other means.Examples of such cases follow.

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AJR:150, April1988 X-RAY GOGS 733

TABLE 1: ComparIson of X-Ray Gogs and Conventional Radiographic Techniques (127 Examinations)

CorrectDiagnosis

The preferred s tudy in terms of:Image

QualityEase of

ExaminationCost of

ExaminationRadiation

Dosen)Conventional techniquesX-Ray GogsSignificance of difference

112 (88%)60” (47%)

p tinyd

1270

p < SC

0127

p < SC

0127

p < SC

097

p < SC

‘Pathological, surgical, or clinical confirmation.b 30 sonograms not included.

Where the correct diagnosis was “no abnormality seen,’ or thereabouts.d Conventional techniques were correct and X-Ray Gogs wrong in 61 cases, while x-Ray Gogs were correct and conventional techniques wrong in 9 cases.

Using McNemar’s test, the author’s IBM clone had difficulty calculating the associated “p’ value. Suffice it to say that p’ is dazzlingly small. Not to worry.‘SC = smoking computer: the clone, using the sign testand attempting to compute the infinitestimal “p” values of chi-square in the megaton (100+) range,

began to smoke: heavily, indoors, and in defiance oflocalordinance and several clearly visible signs.

Exemplary Case Reports

Case 1.-A 4-year-old girl presented to the EmergencyRoom with a hurt finger. The intern, swamped with patients,injudiciously ordered radiographs before examining the child.The finger proved to have been hurt by a bee sting.X-Ray Gog Examination: Soft-tissue swelling dorsal to distal

phalanx. No bony injury seen.Radiographic Examination : Ditto.Comment: No imaging examination was indicated.Case 2.-A 3-year-boy was evaluated for unexplained

fever. Examination revealed otitis media, purulent nasal dis-charge, and tenderness over the left maxilla. The dischargewas sent for culture, and the patient was begun on antibioticsand decongestants. As the child was leaving the clinic, aWaters view of the paranasal sinuses was requested andobtained.X-Ray Gog Examination: No abnormality seen.Radiographic Examination : Radiopacity of the left maxillary

antrum.Comment: The XRG diagnosis was clearly wrong. How-

ever, the clinicians proposed to treat the child the samewhatever the radiographic study showed. The film addednothing except a nebulous entity called “baseline.’Case 3.-A 1-month-old boy presented with projectile

vomiting. Examination revealed mild dehydration, peristalticwaves across the upper abdomen, and a palpable mass(“olive”) in the right abdomen. Sonography demonstrated alengthened pyloris with a wall thickness of 5.5 mm; pyloricstenosis was diagnosed. However, an upper gastrointestinalseries (UGI) was demanded and, after unseemly shouting andfieXings of ego on the part of the dinicians and radiologists,grudingly performed.X-Ray Gog Examination : Barium sulfate suspension, admin-

istered by bottle and nipple, was not seen to flow freelythrough a normal esophagus. The filled stomach was notobserved in several projections. Pyloric lengthening andmarked narrowing (“string sign”) were not noted. Distal to thenarrowing, a normal duodenal sweep and ligament of Trietzwere not appreciated. Hypertrophic pyloric stenosis was notdiagnosed.Fluoroscopic Examination: Ditto, deleting the word “not.”

Comment: The diagnosis of pylonc stenosis was estab-lished prior to further study, if not clinically then certainly bysonography. The unnecessary UGI cost $203 and inflicted anactive marrow radiation dose of perhaps 0.1 rad (0.001 Gy).

Discussion

Red goggles, long a radiologic mainstay until the develop-ment of image intensifiers, are now useless save possibly forstaring at the superficial veins of breasts [5]; indeed, if tintedgoggles are to be worn, they probably should be yellow, toenhance depth perception [6]. Breasts were not visualized inthe current study (although not for want of trying), and anypotential advantage of XRG in maintaining dark-adaptationwas vastly outweighed by several painful collisions with bothfixed and animate objects.The imaging ability of XRG, when judged by the limited,

picayune standards of diagnostic accuracy and image quality,is admittedly abysmal. Nonetheless, this study suggests adefinite role for XRG in the diagnostic imager’s armamentar-ium. The modality is invaluable in the following commonsettings: (1) where radiography is not indicated but someonebadly wants it anyhow; (2) where the results of radiographicstudy will not influence patient management; and (3) wherethe diagnosis has already been established by other means(i.e., “The more times you run over a dead cat, the flatter itgets.” [7]).

It is recommended that every radiologist purchase XRGand modify them to his or her ocular needs. Then, when oneof these settings is encountered, the radiologist should vig-orously recommend to the clinician an XRG examination inlieu of whatever conventional radiation-laden and/or costlystudy is requested. This recommendation may be enhancedby slowly and portentiously donning the XRG, gazing sol-emnly about, and finally stumbling off in the general directionof the patient. Then, having performed the XRG examination,only one diagnosis need be pronounced: “No abnormalityseen.’ The advantages to the radiologist, and especially tothe patient, are obvious. However, further investigation sup-ported by substantial and tax-exempt grants is needed (andisn’t it always?).

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734 EDWARDS AJR:150, April1988

ACKNOWLEDGMENTS

Gratitude is expressed to the unknown founder(s) of April Fool’sDay; to the AJR editorial staff for helping commemorate it; and toCarol A. Edwards and Marcia L. Eamshaw for their photographicassistance.

5. Dunn FH. Red goggles and the mammographic physical examination.Radiology 1970;95:618

6. Kinney JA, Luria SM, Schlichting CL Neri DF. The perception of depthcontours with yellow goggles. Perception 1983;12:363-366

7. Schreiber MH. Wilson’s law of diminishing returns. AJR 1982;138:786-788

REFERENCES

1. Anonymous. Catalog #5. Archie McPhee & Company, Box 30852, Seattle,WA 98103, 1987:20

2. In other words, if X-Ray Gogs were previously tested, the report is buriedsomewhere beyond reach of the author’s bibliographic search service and

(one hopes) beyond reach of the reader’s memory as well.

3. Yes, a feather. Iknow little of matters avian, but my parents did provide achildhood toy microscope, and I do know feathers. X-Ray Gog barbicelsand hamull were clearly discernible at 30X.

4. See any comprehensive medical history text. Direct citation of Dr. Roent-gen might imply that I read German, or have read translations, which I

don’t and haven’t. Give me a break.

Editor’s note. Dr. M. M. Figley explained the origin of April’s FoolDay quite eloquently in a previous issue (MR 1984;142:845): “OnApril Fool’s Day, April 1, it is considered appropriate to tell lies andplay practical jokes on the unwary. This day, also known as All Fool’sDay, is observed almost universally throughout the Western world.The custom is thought to have begun in France, where formal visitswere paid to friends on the first day of April, which was 1 week afterNew Year’s Day (March 25 under the Old Style Gregorian calendar).When New Year’s Day was moved to January 1 in 1752, mock callscontinued to be paid on April 1 as a joke.”

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