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G astRolnt€stlnal gndoSCOPY Editor WILLIAM S. HAUBRICH, M.D. Assistant Editor ELLEN C. SHANNON, M.A. Editor for Abstracts BERNARD M. SCHUMAN, M.D. Address all correspondence to the Editor Scripps Clinic & Research Foundation 476 Prospect Street La Jolla, California 92037 Editorial Consultants WILLIAM H. MAHOOD, M.D. Philadelphia G. GORDON McHARDY, M.D. New Orleans JOHN F. MORRISSEY, M.D. Madison VERNON M. SMITH, M.D. Baltimore BENJAMIN H. SULLIVAN, Jr, M.D. Cleveland ADOLF WIEBENGA, M.D. Amsterdam This subject has been rated 'X' A topic rarely broached in scientific assemblies is money. To speak of the cost in dollars of a procedure, be it diag- nostic or therapeutic, is somehow almost obscene. Why? A good and proper reason that dollar cost is seldom men- tioned-not that it's obscene-is that price is not of first importance. Priority properly goes to answering the ques- tions: Is the procedure feasible? Is it effective? Is it safe? Too often we stop there. The next questions should be: Is the procedure worth the dollar cost to the patient? Can the procedure be offered on a financially sound basis? The article describing the workings of a Gastrointestinal Diagnostic Unit published elsewhere in this issue ap- proaches the subject of dollar cost with fresh candor. We learn that in Toledo a zealous gastroenterologist and an enterprising hospital administrator are making a go of an active gastrointestinal procedure facility. Among costs not specifically itemized in this review are the "fringe benefits" of the clinic employees (unless these are included in the annual salaries) and the expenditure for disposable items, the stocking and laundering of linens, VOLUME 18, NO.2, 1971 83 and so forth. For most hospitals, there is a discrepancy be- tween "charges billed" and actual payment received. We can assume the gastrointestinal unit qualifies as a non- profit venture. Nevertheless, it is hoped we will probe deeper into the actual facts of dollar costs. Let's not be dissuaded by the traditional taboo against calculating the money factor. Our priorities offeasibility, efficacy, and safety stand undimin- ished. For our own and our patients' sakes we can honestly ask, "How much does it cost?". Experimental endoscopy By engaging the cooperation of a sword swallower, Kussmaul, in 1868, began gastroscopy by using man as the experimental animal. With few exceptions, man has con- tinued to occupy both ends of the gastroscope to date. Most of the endoscopy papers are descriptive in nature. Of the 1015 references in Schindler's authoritative test,l only 2 or 3 allude to experimental design. Although there are many reports concerning observations on the incidence and evolution of the natural pathologic anatomy, there are few on either experimentally induced changes, patho- physiologic derangements or attempts at prospective studies with adequate controls. Much less is written con- cerning experimental animal endoscopy. Gastrointestinal endoscopists understood and sympa- thized with those limitations of the art. The discomfort and risk involved with the rigid and semi-flexible lens gastro- scopes prevented any large prospective human study with normal controls, or so it seemed. On the other hand, the cost of the instruments and the esthetic limitations of using the same instrument on man and other animals perhaps retarded the application of endoscopy in the laboratory. Then came the fiberoptic revolution. Not only was the examination more comfortable (most patients prefer per oral endoscopy to a gastric analysis or barium enema), but with the accelerating development of new and improved instruments, most endoscopists have a "last year's model" available for laboratory use. Thus, prospective human studies began to illuminate the literature in the past decade and happily are increasing in frequency. Undoubtedly encouraged by pharmaceutical company financial support, many of these studies have cen- tered about the effects of medications on the stomach, either healthy or diseased. 2 ,3,4 Exceptions to these drug- oriented reports are few but interesting. 5 ,6,7. Although Schindler described his experience with the rigid gastroscope in the dog and pig, he advised against using the expensive and delicate flexible instrument, l and it seems his advice was followed. In 1966 Aoyama et al used a "per-peritoneal gastroscopy" technique to study the cinchophen ulcer because they felt the configuration of the dog's stomach unsuited to examination by regular
