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731

X-Ray

Gogs:

New

David

K. Edwards

1111

Imaging

Preliminary
Modality

X-Ray Gogs, which apparently


or magnetic fields, were compared
a variety of pediatric
conditions.
diagnostic
accuracy
and image
Because of low cost and lack of
cases where radiography
is not

Evaluation

reveal internal anatomy without radiation,


with conventional
imaging modalities

of a

uftrasound,
in evaluating

Conventional
techniques
were preferable
in terms of
quality, and are thus recommended
in most settings.
ionizing radiation,
X-Ray Gogs are recommended
in
indicated,
or where the results of radiographic
study

will not influence


patient management,
established
by other means.

or where

the diagnosis

has already

been

GOGS.
You saw these advertised
in comic books as a child. And you
wanted 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 second
chance to buy, own and operate the famous X-ray glasses. According
to the
package,
it is: the scientific
marvel of the century.
Not sold to communist
countries
on the restricted
list that also prohibits
sales of Cray Supercomputers. $1 .25 each.
Quoted with permission
from [1]
X-RAY

In this age of rapid advances


read the above advertisement
been available to the lay public
in medical context
[2]. Because
never owned XRG, and indeed
childhood
friend with less frugal
not only digital bones but also
personal communication).
The intent of this preliminary
imaging modalities
in a variety
Materials

and

in imaging techniques,
it was mildly surprising
to
and to realize that X-Ray Gogs (XRG), which have
for many years, have evidently
not been examined
of parental skepticism
and parsimony,
the author
life was not riotously
happy thereafter.
However,
a
parents recalls that XRG permitted
visualization
of
the lead in a wooden pencil (Bobby Bubba
Young,
study was to compare
of clinical pediatric
settings.

XRG

with

conventional

Methods

The XRG as received from the vendor (Archie McPhee & Co., Seattle, WA) consisted of
plastic 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 red
feather

Departments
of Radiology
and Pediatrics,
University of California
at San Diego Medical Center,
225 Dickinson
St., San Diego, CA 92103. Address
reprint requests
to D. K. Edwards
Ill.
AJR 150:731-734,
AprIl 1988
0361 -803X/88/1
504-0731
American
Roentgen
Ray Society

[3].

To

permit

a correct

interpupillary

distance

and

to

compensate

for

myopia,

removed 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 nearsimultaneous
XRG observation. The bright light required
by the XRG studies was intermittently
turned on and offduring fluoroscopic procedures.
The Human
Subjects Committee responded to routine petition
manner that was interpreted as approval. Because of the benign

in an

uncouth,

jocular

nature of XRG studies,

informed consent was considered implicit. Pediatric patients (age, 1 day to 10 years) were
employed both because of the authors area of specialization and because adults, encountered in hallways, responded
adversely
to the examiners appearance
(Fig.
2), whereas

EDWARDS

732

AJR:150,

April 1988

Fig. 1.-Obverse
of X-Ray Gogs and
package
label, photographed
on corduroy
(5.5
ridges/cm).
Reverse
of
package label (not shown) contains instructions
and faintly distasteful
insinuations about seeing through clothing.

Fig. 2.-X-Ray
use with prescription

children

Gogs modified
lenses.

for

intrigued, and infants oblivious. The passive voice


possible in this report.
The obviously harmless character of XRG allowed bypassing tedious
laboratory
investigation
involving
rodents
and other vermin.
Following the model of the similarly seminal early communications
of
Wilhelm Roentgen [4], this study was not cluttered with annoying
gibberish about line-pairs, ROC curves, sensitivity/specificity,
and
similar incomprehensibilities.
was

seemed

used

wherever

Results

Preliminary

Evaluations

When used as instructed


(i.e., viewing structures
against a
strong light), the XRG displayed
the soft tissues of the fingers
in a pleasing pink, with darker central regions that were surely
either bones or something
else (Fig. 3). Similarly,
a wooden
pencil thus viewed
revealed
pink edges and a dark central
line that suggested
the pencils graphite core. The potential,
hinted by the manufacturer,
of seeing through
clothing
was
explored
with selected
female staff members
to the point of
eyestrain,
without
success.
Continual
wearing
of the XRG
offered the advantage
that the eyes remained
dark-adapted;
however,
it was difficult to find ones way about the department in what seemed a dense red fog, hounded
by the jeers
of ones colleagues.

Comparative

Study

The results comparing


XRG and conventional
studies are
presented
in Table
1 Conventional
studies
were notably
superior
in furnishing
the correct diagnosis.
The XRG studies
provided
the correct diagnosis
only in those instances
when
the conventional
study also revealed
no abnormality.
An
important
reason
for this disparity
appeared
to be image
quality, which was invariably
inferior with XRG. Indeed, on no
occasions
were axial skeletal
structures,
soft tissue-gas
interfaces,
or administered
contrast
materials
discernible
with
XRG; all that was seen was a pink, patient-shaped
blur.
.

Fig. 3.-Three

of the authors

fingers

viewed

through

X-Ray

Gogs.

On the other hand, XRG was superior


in terms of ease of
examination
(one had only to look at the patient with a bright
light in the background),
cost (negligible),
and radiation
dose
(nil). With these advantages
in mind, the cases were reviewed
retrospectively
to define the actual benefit afforded the patient
by the imaging study; 13 cases (1 0%) were found in which
the benefit of the XRG study was at least the same as that
of the conventional
study. These were cases in which at least
one of the following
pertained:
(1) the radiographic
study was
not indicated;
(2) no change in patient management
would
occur whatever
the results of the radiographic
study; or (3)
the diagnosis
was already firmly established
by other means.
Examples
of such cases follow.

X-RAY

AJR:150,

April1988

TABLE

1: ComparIson

of X-Ray

Gogs

and Conventional

Correct
Diagnosis
Conventional techniques

X-Ray Gogs
Significance of difference
Pathological,
b 30 sonograms
d

surgical, or clinical
not included.

GOGS

Radiographic

Image
Quality

Techniques

(127 Examinations)

The

s tudy in

preferred

Ease of
Examination

127
0
p < SC

112 (88%)
60 (47%)
p
tinyd

733

0
127
p < SC

terms of:

Cost of
Examination

Radiation
Dosen)
0
97
p < SC

0
127
p < SC

confirmation.

Where the correct diagnosis


was no abnormality
seen,
Conventional
techniques
were correct and X-Ray Gogs

or thereabouts.
wrong in 61 cases,

while

x-Ray Gogs were correct

and conventional

techniques

wrong

in 9 cases.

Using McNemars
test, the authors
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+)
began to smoke: heavily, indoors, and in defiance of localordinance
and several clearly visible signs.

Exemplary

Case Reports

Case 1.-A
4-year-old
girl presented
to the Emergency
Room 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 discharge, and tenderness
over the left maxilla. The discharge
was sent for culture, and the patient was begun on antibiotics
and decongestants.
As the child was leaving the clinic, a
Waters view of the paranasal
sinuses
was requested
and
obtained.
X-Ray Gog Examination:
No abnormality
seen.
Radiographic
Examination : Radiopacity
of the left maxillary
antrum.
Comment:
The XRG diagnosis was clearly wrong. However, the clinicians proposed
to treat the child the same
whatever
the radiographic
study showed.
The film added
nothing except a nebulous entity called baseline.
Case 3.-A
1-month-old
boy presented
with projectile
vomiting.
Examination
revealed
mild dehydration,
peristaltic
waves across the upper abdomen,
and a palpable
mass
(olive)
in the right abdomen.
Sonography
demonstrated
a
lengthened
pyloris with a wall thickness
of 5.5 mm; pyloric
stenosis
was diagnosed.
However,
an upper gastrointestinal
series (UGI) was demanded
and, after unseemly shouting and
fieXings of ego on the part of the dinicians
and radiologists,
grudingly performed.
X-Ray Gog Examination : Barium sulfate suspension,
administered by bottle and nipple, was not seen to flow freely
through a normal esophagus.
The filled stomach
was not
observed
in several
projections.
Pyloric
lengthening
and
marked narrowing
(string sign) were not noted. Distal to the
narrowing,
a normal duodenal sweep and ligament of Trietz
were not appreciated.
Hypertrophic
pyloric stenosis was not

diagnosed.
Fluoroscopic

Examination:

Ditto, deleting

the word

not.

range,

Comment:
The diagnosis
of pylonc stenosis was established prior to further study, if not clinically then certainly
by
sonography.
The unnecessary
UGI cost $203 and inflicted an
active marrow radiation dose of perhaps 0.1 rad (0.001 Gy).

Discussion
Red goggles, long a radiologic mainstay until the development of image intensifiers,
are now useless save possibly for
staring at the superficial veins of breasts [5]; indeed, if tinted
goggles are to be worn, they probably
should be yellow, to
enhance depth perception
[6]. Breasts were not visualized in
the current study (although not for want of trying), and any
potential advantage
of XRG in maintaining
dark-adaptation
was vastly outweighed
by several painful collisions with both
fixed 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
a
definite role for XRG in the diagnostic imagers armamentarium. The modality
is invaluable
in the following
common
settings: (1) where radiography
is not indicated but someone
badly wants it anyhow; (2) where the results of radiographic
study will not influence
patient management;
and (3) where
the diagnosis has already been established
by other means
(i.e., The more times you run over a dead cat, the flatter it
gets. [7]).
It is recommended
that every radiologist
purchase
XRG
and modify them to his or her ocular needs. Then, when one
of these settings is encountered,
the radiologist should vigorously recommend
to the clinician an XRG examination
in
lieu of whatever
conventional
radiation-laden
and/or costly
study is requested.
This recommendation
may be enhanced
by slowly and portentiously
donning
the XRG, gazing
solemnly about, and finally stumbling
off in the general direction
of the patient. Then, having performed the XRG examination,
only one diagnosis
need be pronounced:
No abnormality
seen. The advantages
to the radiologist,
and especially to
the patient, are obvious.
However,
further investigation
supported by substantial
and tax-exempt
grants is needed (and
isnt it always?).

734

EDWARDS

ACKNOWLEDGMENTS
Gratitude is expressed to the unknown founder(s) of April Fools
Day; to the AJR editorial staff for helping commemorate
it; and to
Carol A. Edwards and Marcia L. Eamshaw
for their photographic
assistance.

AJR:150,

April1988

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 depth
contours
with yellow goggles. Perception
1983;12:363-366
7. Schreiber
MH. Wilsons
law of diminishing
returns.
AJR 1982;138:
5.

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 buried
somewhere
beyond reach of the authors
bibliographic
search service and
(one hopes) beyond reach of the readers memory as well.
3. Yes, a feather. I know little of matters avian, but my parents did provide a
childhood
toy microscope,
and I do know feathers.
X-Ray Gog barbicels
and hamull were clearly discernible
at 30X.
4. See any comprehensive
medical history text. Direct citation of Dr. Roentgen might imply that I read German,
or have read translations, which I
dont and havent. Give me a break.

Editors note. Dr. M. M. Figley explained the origin of Aprils Fool


Day quite eloquently in a previous issue (MR 1984;142:845):
On
April Fools Day, April 1, it is considered
appropriate
to tell lies and
play practical jokes on the unwary. This day, also known as All Fools
Day, is observed
almost
universally throughout the Western world.
The custom is thought to have begun in France, where formal visits
were paid to friends on the first day of April, which was 1 week after
New Years Day (March 25 under the Old Style Gregorian calendar).
When New Years Day was moved to January 1 in 1752, mock calls
continued to be paid on April 1 as a joke.