Information on the skin biopsy
Historical background
The biopsy has a central place in medical
diagnostics. Despite the development of illustrative diagnostics
and modern serological procedures for obtaining evidence,
the histo-pathological assessment of tissue remains the “gold
standard” just the same. This applies in particular
to skin ailments, firstly due to easy access, and secondly
due to the high meaningfulness of dermato-histopathological
examinations. Over the last few decades, skin afflictions
have been regularly given biopsies, and the histo-pathological
findings – unlike diseases afflicting other organs –
can easily be correlated with the clinical picture. Dermato-pathology
is thus far more advanced compared with the pathology of other
organ systems.
The stimulus in this development led to the
introduction of the biopsy over 100 years ago. Even before
then, skin ailments were examined microscopically; however,
this was done only casually, in connection with autopsies
or “necropsies”. Unlike the situation in ”necropsy”,
i.e. the removal of dead tissue, in 1879 the dermatologist
 Ernest
Besnier coined the term “biopsy” for
the removal of living tissue. At that time, Besnier wrote:
”Cutaneous changes were not examined only by a set
of necropsies in a definitive form, but many questions relating
to the living have also been clarified by carrying out histological
examination of small slithers of tegument or fragments of
diseased tissue. This method of examination, in fact a biopsy
(a neologism that we propose for the name of this new type
of examination), is a regular procedure in clinical diagnostics,
whose significance is great. One generally requires only very
small skin or tissue fragments, removed by skilled hands using
a lancet in order to obtain the most clear-cut and satisfactory
histological results."
Besnier recommended the biopsy not as a routine
diagnostic procedure, but confined its use to scientific issues:
“We hope it will be accepted that we do not propose
introducing this clinical vivisection, where it is a case
of diagnosis of afflictions described in the usual or traditional
form, whose clinical picture has been summed up. It should,
let it be noted, be reserved for those cases in which reliable
diagnosis is absolutely impossible without using this tool
at the present state of our knowledge, or where we have to
determine a doubtful case of the nature of the affliction,
which would never lend itself to being clarified by a necropsy."
The reason for Besnier’s reticence
was primarily that patients were not to suffer painful intervention
without compelling reasons, since facilities for a local anaesthetic
were restricted at the time. Until the 1880s, a local anaesthetic
was performed essentially only by numbing the area through
the application of ethyl chloride or chlora-ethyl, and in
many instances anaesthetics were avoided altogether. Change
came only in 1884, when the Viennese ophthalmologist
Carl
Koller reported pain-free cataract operations after
instilling a cocaine solution into the eye. This news spread
rapidly, and just a year later cocaine was also injected in
the skin, for example, by American surgeon William Halstedt,
who became dependent on cocaine over the course of his research.
Despite these side-effects, around the end
of the 19th century infiltration anaesthetics came into use
for smaller interventions and played a large part in turning
the biopsy into a standard diagnostic procedure. The increase
in skin biopsies went hand-in-hand with the development of
various biopsy techniques. In 1876 Heinrich Auspitz and Hans
von Hebra had introduced the sharp spoon. In 1887 the American
dermatologist
Edward
L. Keyes described the »
Punch«,
which was originally developed by him to remove powder-crystals
in the face. He portrayed them as “skin punches...with
a sharp cutting-edge and diameter upwards of one millimeter
... When these small instruments are placed upon the skin
and rotated vigorously, they cut a round piece out of the
tegument, whose diameter matches their lumen and whose depth
can be varied, depending on the pressure exerted”.
(15)
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