Sunday, February 24, 2008

Using X-rays to Sell Shoes

Consider this text from a radio commercial circa the late 1940's.
Every parent will want to hear this important news! Now, at last, you can be certain that your children's foot health is not being jeopardized by improperly fitting shoes.
Wow! How could any parent resist this call to action? If you're not convinced, consider this quote by J.J. Lowe:
With this apparatus in his shop a shoe merchant can positively assure his customers that they never need wear ill-fitting boots and shoes; that parents can visually assure themselves as to whether they are buying shoes for their boys and girls which will not injure and deform the sensitive bone joints.
Fortunately, there's no need for alarm. The product being hawked in the quotes above -- a shoe-fitting fluoroscope -- is no longer used.

The idea of using X-ray technology to improve the fit of shoes probably arose during World War I. Shoe-fitting fluoroscopes were patented in the U.S. and the U.K. in the 1920's and were common fixtures in shoe stores throughout North America and Europe from the late 1920's through the 1950's.

In an excellent review of this topic, Duffin and Hayter state:
In our opinion, however, the shoe-fitting fluoroscope was nothing more nor less than an elaborate form of advertising designed to sell shoes. It entered a well-established culture of shoe-selling hucksterism that relied on scientific rhetoric; it took advantage of the woman client newly accustomed to the electrification of her home and the patter of experts' advice about "scientific motherhood"; it neatly sidestepped the thorny problem of truth in advertising that became an issue in the interwar years; and it enticed thrill-seeking children into shops where salesmen could work their magic.

I can still remember looking at my 6 year-old feet through one of these devices in my local Sears store. It was extremely cool to watch my toes wiggle on the green glowing screen, and I was very disappointed when the machine was eventually removed from the store. However, I felt much differently about these devices once I became a radiologist and began to learn more about radiation and its effects on the body.

Physicians use fluoroscopy to perform all sorts of patient procedures ranging from barium enemas to cardiac catheterizations to the placement of prosthetic joints. However, we only expose our patients to the minimum amount of radiation necessary and we keep ourselves way the heck out of the way of the X-ray beam.

By contrast, shoe-fitting fluoroscopes were badly designed, meant to be used by barely-trained shoe salesmen, and gave a considerable dose of radiation to one's feet and other body parts. A customer using this machine would be essentially standing on the the X-ray tube, separated from it only by 1 mm of aluminum shielding. Body parts in the main X-ray beam (customer's feet and salesman's hands) received most of the dose.

But wait -- there's more! These X-rays not only went up through the feet to the fluoroscopy screen, but continued upwards, through the heads, thyroids and eyes of the users. Not exactly an optimal design. Even body parts not directly exposed to the main beam could receive a considerable dose from scatter radiation. As an exercise in discomfort, look at the diagram below and visualize just what sort of dose your own personal gonads would get while standing on this thing.

Drawing after Bushong SC and West WD. Exposure from a Shoe-Fitting Fluoroscope. Health Physics 1970;18:575-576.

Duffin and Hayter state:
In addition to the dose received by the feet, the entire body of the customer -- along with her parent and the attending salesman -- was bathed in radiation; others in the shop were also being irradiated through the walls of the machine. In the waiting-room chairs, the permissible daily dose could be received by a single person in one hour.
It's therefore ironic that these machines were targeted at two of the more radiation-sensitive segments of the customer base: children and women in their child-bearing years. The following quotation is excerpted from the installation instructions of one machine:
Of course, it should face the ladies' and children's departments by virtue of the heavier sales in these departments.

With the machines of the time, a child could be exposed to 10 to 116 R in a 20-second period, a dose sufficient to cause radiation burns to the skin. If one considers further that a given child might try on several pairs of shoes per visit with several visits per year, these multiple exposures could add up to an even higher yearly dosage. To put this in perspective, the daily permissible dose for radiation workers in 1946 was 0.1 R.

By the way, the question, "Dude, what's my radiation dose?" is not unlike another question: "Dude, how much does it cost to fly to Chicago?". The answer to both questions is, "It depends." I've paid anywhere from $300 to $1500 to get to Chicago, depending on factors such as how long before the flight I booked my ticket, coach vs. first class, one-way vs. round-trip ticket, and my length of layover. The effective radiation dose depends upon a similar number of variables, such the type of radiation, the length of the exposure and just which body part is exposed. Exposure to critical tissues such as the eye, thyroid and gonads is a much bigger deal than exposure to a relatively radiation-insensitive area like the foot.

Were the medical experts of the day asleep at the wheel while all of this was going on? Not really. The British X-Ray and Radium Committee of Great Britain issued recommendations for workplace radiation dosage in 1921, and Americans followed suit in 1922. However, these machines remained unregulated until 1948, when New York became one of the first jurisdictions to regulate their use. The American College of Radiology published a warning editorial in the Journal of the American Medical Association in April 1949. Its conclusion:
The bitter fact remains that fluoroscopy simply cannot be really safe in the hands of those untrained to its use and relatively ignorant of its dangers.
This was also a time of growing post-war public concerns about radiation safety, likely related to WWII events such as the Manhattan Project and the atomic bombing of Japan. Pennsylvania became first state to ban these shoe-fitting fluoroscopes in 1957. Thirty-three other states followed suit with some form of legislative action. In 1963, these devices were finally banned in the U.S.

Has anyone ever actually been harmed by shoe store fluoroscopy? Alas, only anecdotal evidence is available to help answer this question. In 1957, Kopp described a case of a shoe saleswoman who developed chronic radiation dermatitis on her own feet. More recent reports of basal cell carcinoma of the foot attributed to shoe store fluoroscopy have been reported by Oster-Schmidt in 2002 and Smullen in 2007.

From what we know of radiation exposure in animal experiments and from studies of atom bomb survivors and nuclear industry workers, a number of other problems can be hypothesized: foot-bone deformities in child customers, and testicular tumors and leukemia in salespeople. Unfortunately, due to the undocumented dosage and time course of the exposure, and to the long lag period between radiation and some of its side effects (e.g. cancer), the long term health consequences of shoe store fluoroscopy will likely never be known.

Although shoe-fitting fluoroscopes are no longer used, their story remains a cautionary tale in the ongoing struggle against quack medicine. The storyline of shoe-store fluoroscopy follows an arc familiar to woo-watchers:
  1. a real physical phenomenon or technology is discovered
  2. unsubstantiated health claims are made about it
  3. the potential dangers are discounted
  4. quack usage becomes popular and spreads widely
  5. government regulation catches up slowly, if not circumvented politically
However, unlike forms of woo which are essentially placebos (e.g. homeopathy and acupuncture), shoe-fitting fluoroscopy was based on a phenomenon whose effects could actually be objectively measured: ionizing radiation. The scientific research necessary to demonstrate the harmful effects of such radiation took decades to accumulate, but eventually became overwhelming enough to convince even politicians and regulators to do the right thing, just as the fad was passing.


The images of the fluoroscope and the shoe-fitting certificate are used with the kind permission of Dr. Paul Frame, of the Oak Ridge Associated Universities Museum.

Many of the historical details for this post were culled from three excellent resources.  I highly recommend reading the originals:

1) the online exhibit on shoe-fitting fluoroscopy at the ORAU Museum, gives a very nice introduction into the history of this device with some excellent illustrations.

2) Baring the Sole: The Rise and Fall of the Shoe-Fitting Fluoroscope is the definitive history of this device, and was published in 2000 by Jacalyn Duffin and Charles Hayter, Isis 2000;91(2):260-282.
3) When the solution is the problem: a brief history of the shoe fluoroscope.  Nedd CA 2nd.  AJR 1992;158:1270.


pegleghippie said...

Maybe it's because I'm only 20, but, really? There was a time where shoe salesmen used x-rays on people's feet? to see if a shoe fit? I'm not sure I believe you. If true, I'm putting this down as another reason to never trust salesmen.

The Samurai Radiologist said...

@ pegleghippie: There are no end of wacky things people will claim, sell or buy when marketing is given more credence than evidence.

I applaud anyone of 20 (or any age) for being skeptical, i.e. demanding evidence of wild claims. It's very reasonable take my memories from age 6 with a grain of salt. :-) However, please feel free to look at my primary sources for this post, or visit the ORAU museum and see one of these devices with your own eyes.

Sylvia said...

I'm also in my twenties, but I had the opposite reaction to pegleghippie's: I saw the title of the post and thought, "Whoa, someone's debunking the story about x-ray machines in shoe stores? I coulda sworn that was for real..."

Margaret said...

I'm 68 years old and remember clearly as a child standing in the fluoroscope machines in shoe shops to check the fit of shoes on my feet. As I had one foot slightly deformed by earlier polio, we went through this process repeatedly at shoe-buying time.

Paula said...

the patient said.....
I have recently been diagnosed with thyroid cancer - I attribute this to the frequent use of the shoe x-ray machines in shoe shops.
We loved getting our feet x-rayed and looked at our bones in our feet to see if the shoes fitted.
oh - the lessons we have learned over the years.....

Samantha in Oz said...

Boy oh boy. Thanks for this informative and unsettling post.

At a recent family gathering my 66-year-old mother was reminiscing about having her feet x-rayed at the local shoe store as a kid.

Like your first commenter, I had trouble believing her story.

But it got even worse: my mother didn't just have her feet x-rayed once or twice. Unfortunately, the shoe store was on her route to school, so she and her best friend went in to x-ray their feet every morning and afternoon, before and after school, for a period of a few months (at which time my mother's family moved to a different town).

My mother has very recently been diagnosed with bone marrow disease. She's also had breast cancer and basal cell carcinoma in the past.

diabetes dancer said...

Wow, I'd forgotten about this. I can also clearly remember putting my feet into that wooden box and being fascinated with the xray pictures. I have no idea how often this happened, but it was more than a couple of time, for sure.

I also have had three different types of cancer during my life so far (63) and have been wondering if there might be a reason for any of them, since I don't have any significant environmental nor genetic risk factors (I checked).

It would be great if someone was interested in doing some good retrospective research on this question. Another decade or two and we won't all be around to ask anymore.

Nonnie said...

Good article. I too recall using these machines. I almost wrote, and probably should have written "I recall playing on these machines". I definitely remember my older brother and I x-raying each others feet while our mom was with the salesperson, fitting our younger brother. We must've spent a half hour or so doing that! Nice, huh?

I grew up, became a nurse and since then have had occasion to think how lucky we've been to escape a bad result from that. I can't resist adding "so far".

Grampledor said...

I was a department store brat during the late 40s and the 50s; my dad owned a portrait studio in Waterbury, CT and, don't you know, the shoe department was across the aisle.

I can't remember how many times my friends and I used to use the shoe-store fluoroscope to look at any parts of our bodies we could fit in the slot. I've had two kids, so I guess it's fortunate that that part of me wouldn't fit in the apparatus.

So otherwise im doig redal, fiune bud rlKJASM kSE kksdpon. Grabble freen sdpoyt dglub. Ut wisi enim ad min im veniam, quis nostrud exerci tation... bt iT gos away after a while. :-)

Gailsmile said...

We lived in Huntington, Long Island, NY in the late 60's. I was about nine years old. I remember a large odd looking machine sitting in the corner of one of our local shoe stores. My mother told me to stay away from it, with a warning about x-rays. I would like to believe that it was just sitting there, not ever being used anymore, due to its bulk?

Debbie Montesano said...

My sister and I repeatedly used this machine to xray our feet during each visit to the Buster Brown show store, while waiting for our mother to finish buying shoes for us four kids. Since I've recently been having a lot of pain in my feet and toes--no doubt arthritis--I can't help wondering about the long-term effect of such exposure.

Doctor Diane said...

Had a crush injury to foot at age five.
Remember those machines well.
Had breast cancer and was at low risk, also weird kind of chronic lymphocytosis.
Left with thin scar covering bone of foot and now am adult physician and had to undergo skin grafts, bone grafts, hyperbaric chamber for these old wound

David Millson said...

From your brief mention of it, I'm not sure how the shoe x-ray machine relates to your foot injury and subsequent cancer, though I'm certainly sorry you've undergone so much.

I was a department store brat in Waterbury, CT. My Dad had a portrait studio directly down the aisle from the shoe department.

I can't begin to count the time I put feet, hands -- anything that could fit -- under the x-rays, and then swapped places with my friend(s).

My father died of metastasized colo-rectal cancer at 54. My mother overcame stomach cancer and died of lung cancer at 82.

I have no cancers. I'm 70. I do have MS, fibromyalgia and osteoarthritis... but I don't think I can blame the x-ray toy for that.

X-Ray chick said...

I just recently graduated from a BA degree and had been a rad tech for not very long (almost 3 years) and it's the first time I had heard of the shoe fluoroscope. This is an amazing report, thank you for sharing this!

Cautionary Tales said...

They were all around the world. I have now found out that I was almost certainly exposed to the machine in the 60s in Australia, as they were not taken off the market until around 1970 and I am a youthful 49. As a doctor I have to say that its disgraceful and the medical community around the world should have demanded that the machines were banned as the risks were obvious way back in the 40s.