Chapter 26 - Morticians.pdf

26 

Morticians 

Occupational Description 

Morticians take custody of the dead and arrange 

funerals, cremation, and burials. The term 

mortician is frequently used synonymously with undertaker, 

funeral director, funeral service worker, and 

embalmer. 25 A mortician’s work includes some or all of the 

following: collection of the dead body from the hospital or 

home, embalming, cosmetic restoration, provision of a casket, 

arranging cremation, a funeral, and burial. In the 

United States, most dead bodies are embalmed prior to cremation 

or burial. Embalming and preservation of dead bodies 

has been practiced since before the time of the ancient 

Egyptians, 44 who believed that the embalming process 

actually prepared the dead for entry into the afterlife. In 

modern society, preserving dead bodies from decomposition 

is sometimes required for sanitary reasons, such as 

when transporting a body for long distances prior to burial. 

Embalming is a practice involving religious, ethical, 

cultural, psychological, and practical issues. 

Licensure of morticians in the United States varies and is 

not required in all states. 25 There are approximately 14,400 

funeral homes in the United States, with 71,000 employees. 

49 In most cases, a funeral home will have at least one 

274 

▼ 

ANTHONY SURUDA 

Mortician wearing personal protective 

equipment prepares to attend to a 

deceased person. (Courtesy of Lydia 

Forte Roberts Photography, with 

permission.) 

embalmer. Employees who are not trained or licensed as 

morticians may assist in embalming, so the number of 

workers exposed or potentially exposed to chemicals in the 

embalming process may well exceed 71,000. 

Embalming can be accomplished by the use of several 

different methods. In general, chemicals are used that coalesce 

and cross-link proteins and other organic molecules 

and thus retard degradation. There are two physical methods 

for applying embalming products, which may be combined: 

(1) perfusion of the body or body area with 

embalming fluid by instillation into a vein, artery, or body 

cavity and (2) preservation by surface contact with chemicals 

in the form of gels, creams, or powders. Embalming 

solutions and powders contain a variety of chemicals that 

may include formaldehyde, phenol, glycerol, alcohols, glutaraldehyde, 

and coloring agents. Specialized creams and 

solutions may be used on facial areas when public viewing 

is planned. Gels containing formaldehyde are applied to 

areas that are especially difficult to perfuse, such as the 

hands and feet. Different procedures and solutions are used 

for normal, intact bodies, for bodies that have been altered 

by violence or by autopsy, and for bodies that are partly 

decomposed. Bodies donated to medical schools for 

anatomic research are given additional injections of fluids 

containing glycerin, phenol, methanol, and ethanol in order 

to maintain tissue flexibility for dissection. 8

276 SECTION I / Occupational Toxicology 

The body to be embalmed is placed on a metal table that 

is slightly inclined and equipped with a drain. The body is 

then cleaned, shaved, and arranged in a natural position. 

Next, a large-bore needle is inserted into an artery and 

embalming fluid is then infused. Venous blood is then 

allowed to drain out. Water is used to wash blood and any 

leaking embalming fluid from the table. 31,54 The viscera 

are embalmed by puncturing the abdominal wall with a 

trochar and introducing a more concentrated embalming 

solution into the abdominal cavity. Several hours later, this 

fluid is drained and the hole sealed with a button. 

Embalming gels and creams are applied to the face, feet, 

and hands. Cosmetic restoration may be done in addition 

to embalming. 

In the case of autopsied bodies, the viscera are 

embalmed separately. Embalming of autopsied bodies 

takes longer, requires larger volumes of embalming fluid, 

and results in potentially higher exposures of airborne 

chemicals than embalming of intact bodies. Embalming of 

autopsied or partly decomposed bodies commonly results 

in leaks and spills of embalming fluid onto the embalming 

table, which may also increase airborne exposure to 

formaldehyde or other chemicals that may be used. 

Potential Exposures 

The potential chemical exposures for morticians and mortuary 

personnel are listed in Table 26–1. Exposure to various 

biologic hazards such as human immunodeficiency 

virus, hepatitis virus, and other infectious agents may occur 

through inhalation, skin contact, or needlestick injury while 

the body is being prepared or during the injection of 

embalming fluids. Exposure to chemical substances may be 

through inhalation or dermal absorption. It is common practice 

for embalmers to wear personal protective equipment 

such as gloves, aprons, and safety glasses to reduce the 

potential for exposures. An important means for controlling 

TABLE 26–1 ▼ Potential Chemical Exposures for Morticians 

airborne exposures involves adequate ventilation of the 

embalming area, with the flow of air away from the breathing 

zone of the embalmer and the air exhausted from the 

building. 40 Ventilation systems in current use in embalming 

rooms may not always be adequate to control airborne 

exposures. Of special concern is the development of important 

airborne concentrations of formaldehyde. 26,36 In one 

case, recirculated formaldehyde-containing air in a mortuary 

brought contaminated air back into the building. 40 

The major airborne chemical of concern in embalming 

rooms is formaldehyde. Average exposure levels to 

formaldehyde during embalming have been reported to 

range as high as 3 parts per million (ppm). 26,36,40,50,54 This 

level is considerably more than the U.S. Occupational 

Safety and Health permissible exposure limit of 0.75 ppm 

as an 8-hour time weighted average or the short-term exposure 

limit of 2 ppm for a 15-minute period. 42 Average 

exposures for morticians to formaldehyde are comparable 

to those in other industries, but short-term or “peak” exposures 

may actually be much higher. 6 

Exposure Source Route of exposure Adverse effects Permissible limit 

Infectious agents Bodies and body Airborne, skin needlestick, Blood-borne diseases and 

fluids splash tuberculosis 

Formaldehyde Embalming fluids, Airborne, skin Contact dermatitis, urticaria, 0.75 ppm avg 

avg (STEL)* disinfectants asthma, suspect 2.0 ppm short-term exposure 

carcinogen limit (OSHA) † 

Glutaraldehyde Embalming fluid Airborne, skin Contact dermatitis, asthma 0.2 ppm (NIOSH) ‡ 

Methanol Embalming fluid Airborne, skin Irritant; ocular damage 200 ppm (OSHA) 

Isopropanol Embalming fluid, Airborne, skin Irritant 400 ppm (OSHA) 

disinfectants 

Phenol Embalming fluid Airborne, skin Irritant; toxic to liver, kidney, 5 ppm (OSHA) 

(central nervous system if 

ingested) 

Dyes, perfumes, Cosmetic restoration Skin Contact dermatitis 

cosmetics 

Floral Skin Contact dermatitis 

arrangements 

*STEL, short-term exposure limit. 

† OSHA, Occupational Safety and Health Administration. 

‡ NIOSH, National Institute of Occupational Safety and Health. 

▼ (Courtesy of Lydia Forte Roberts Photography, with permission.)

Factors that may increase airborne exposure to 

formaldehyde are listed in Table 26-2. The use of 

paraformaldehyde powder, a polymer that spontaneously 

decomposes to formaldehyde, can result in high airborne 

concentrations of formaldehyde. When paraformaldehyde 

is used, there is also a potential for inhalation of particulate 

matter containing formaldehyde. 26 The use of disinfectant 

sprays containing formaldehyde to “spray down” 

embalming tables and equipment also may contribute to 

airborne formaldehyde exposure. 8 

Other components of embalming fluid with relatively 

high volatility that may be inhaled by embalmers include 

glutaraldehyde, methanol, isopropyl alcohol, and phenol. 

Ambient air concentrations of these chemicals in embalming 

areas have been reported by some to be low or below 

the limit of detection. 8,54 

Embalming chemicals may be absorbed directly through 

the mortician’s skin. This hazard may be limited by wearing 

gloves, aprons, and safety glasses. However, it is possible 

for formaldehyde to be absorbed through the 

embalmer’s skin even when gloves are worn. Common 

surgical gloves become permeable to formaldehyde solutions 

in 1–15 minutes after contact with concentrations in 

the 9% to 37% range. These concentrations are similar to 

the concentrations found in many pathology laboratories. 47 

Fluids used for embalming are usually diluted to a 

formaldehyde concentration of 5% or less. Since glove 

permeability to chemicals is related to concentration, the 

most important hazard would arise from spills of undiluted 

embalming fluid. 

Contact dermatitis resulting from exposure to embalming 

fluid is an occupational hazard of morticians. 

Apprentice embalmers are more likely to complain of 

mucous membrane irritation from embalming chemicals 

than experienced embalmers. 22 The prevalence of contact 

sensitivity to formaldehyde and glutaraldehyde was 

reported as 4% and 10%, respectively. 22 Although we have 

no way to quantify this, it was our observation during a 

field study 50 that embalming fluids with lower formaldehyde 

content were favored by embalmers who were aware 

that formaldehyde was a suspected human carcinogen. 

Since the low-formaldehyde fluids had increased amounts 

of glutaraldehyde, their use might increase the possibility 

of contact dermatitis. Morticians who handle floral 

arrangements are also at risk of contact dermatitis from 

plant sensitizers. 15 

The respiratory function of morticians tends to be similar 

to that of control populations who are not occupationally 

exposed to formaldehyde. 31 Mortality studies of 

morticians have not found excess deaths from nasal cancer 

TABLE 26–2 

▼ Factors Which Increase Airborne 

Exposure to Formaldehyde Among 

Morticians 

Embalming autopsied body 

Use of paraformaldehyde powder 

Spills or leaks of embalming fluid 

Inadequate room ventilation 

or other respiratory cancers that might be related to 

formaldehyde exposure. 18,30,53 However, the statistical 

power of these studies to detect excess cancers was limited. 

The largest of these studies included 4,046 deaths, 

with only 1.7 deaths expected from nasal cancer. There is 

one case report of nasal cancer in an embalmer with 24 

years experience. 10 

Clinical Toxicology 

of Formaldehyde 

Morticians / 26 277 

▼ (Courtesy of Lydia Forte Roberts Photography, with permission.) 

Formaldehyde is a gas at room temperature with an irritating 

odor. It polymerizes readily and is readily soluble in 

water. Gaseous formaldehyde is not available commercially; 

pure formaldehyde can be obtained from spontaneous 

decomposition of paraformaldehyde. Formaldehyde 

is commonly available as formalin, a 37% to 50% aqueous 

solution that contains methanol. Methanol is present in formalin 

solutions in order to inhibit polymerization. 

Formaldehyde is actually a normal metabolite in the 

human body that results from the metabolism of certain 1carbon 

reactions. 38 Consequently, formaldehyde is normally 

present in the human body in low concentrations. 32 

Over 1 million U.S. workers may be exposed to formaldehyde 

in manufacturing and in health-related professions. 6 

Individuals living in homes containing particle board or 

urea-formaldehyde foam insulation may be exposed to low 

levels of formaldehyde by virtue of the release of 

formaldehyde from these materials. However, the health 

effects of formaldehyde in this setting may not be consequential. 

Formaldehyde is also found in many consumer products. 

The Food and Drug Administration lists formaldehyde as 

being present in over 800 cosmetic preparations, and 

formaldehyde is present in products such as glossy papers, 

color photographs, and permanent press clothing. 38 In 

Sweden and Japan, formaldehyde is forbidden in cosmetics. 

15 Cigarette smoke contains up to 40 ppm formaldehyde. 

21 All persons, even those living in wilderness areas, 

may be exposed to small amounts of formaldehyde in air


that may originate from vehicle exhaust, industrial 

processes, or natural sources. 21 

PATHOBIOLOGY 

Acute exposures to formaldehyde may occur from the gas 

or from contact with the liquid form as formalin. At air 

levels of 0.5–2 ppm, formaldehyde may function as an irritant 

and cause mild eye and mucous membrane complaints 

(Table 26–3). Most individuals do not tolerate exposures 

above 5 ppm and will attempt to leave the area. 14 Acute 

pulmonary edema was reported after inhalation of 

formaldehyde over a period of several hours while preparing 

brain sections in a pathology laboratory. 45 The exposure 

level was not measured in this case, but the victim’s 

wife actually smelled formaldehyde on his breath after he 

left the laboratory. Inhalation of more than 50 ppm 

formaldehyde may cause serious respiratory injury, and 

death has been reported. 14 Eye injury does not normally 

result from airborne formaldehyde because increased 

blinking and closure of the eyes tends to protect the 

cornea. 38 Liquid formalin is extremely irritating to the eye, 

and direct exposures have been reported to cause corneal 

opacity and loss of vision. 38 

Ingestion of a few drops of 40% formalin solution has 

caused death in a child, 39 and ingestions of 50–250 cc as 

overdoses by adults have also been fatal. 14,39 Postmortem 

findings following acute formaldehyde poisoning may 

include gastric congestion and erosion, pulmonary edema, 

glottic and tracheal swelling, and discoloration of mucous 

membranes in the mouth. 14,39 Exposure of hemodialysis 

patients to formaldehyde in contaminated dialysis water 

has caused hemolytic anemia43 by depleting red blood cell 

adenosine triphosphate. 

Acute exposure to formaldehyde may reversibly diminish 

the sense of smell. 38 Acute and chronic skin exposure 

may produce irritation and peeling, as well as an allergic 

contact dermatitis. 38 The ingestion of formaldehyde has 


▼ Acute Effects of Formaldehyde Exposure 

Area affected Effects 

Gaseous formaldehyde 

Eyes Irritation, tearing 

Upper respiratory tract Irritation 

Lungs Irritation, bronchoconstriction, 

pulmonary edema (at high 

exposures) 

Nose Temporary reduction in ability 

to smell 

Aqueous formaldehyde 

Blood Hemolytic anemia in dialysis 

patients 

Eyes Corneal opacities and blindness 

Mouth and esophagus Coagulation of mucous 

membranes 

Lungs Mucosal and parenchymal 

edema 

Gastrointestinal tract Esophageal structure; gastritis 

Skin Irritation, allergic contact 

dermatitis 

been reported to be associated with the development of 

urticaria and a skin eruption. In 1909 the U.S. Department 

of Agriculture evaluated formaldehyde as a food preservative 

and administered 100 mg formaldehyde daily in milk 

to normal volunteers for 15 days. Four of the 15 subjects 

developed itching and a skin rash. 39 

Chronic skin exposure to formaldehyde may cause contact 

dermatitis and occasionally urticaria (Table 26–4). 

Formaldehyde has been reported to be the 10th leading 

cause of contact dermatitis in patients who undergo patch 

testing. 38 The contact dermatitis resulting from formaldehyde 

is sometimes more pronounced in sun-exposed areas, 

raising the possibility that there may be a photoallergic 

component associated with this phenomenon. 33 

There is controversy concerning whether formaldehyde 

exposure can cause asthma. 5 Hendrick and Lane 19 reported 

on two nurses exposed to formaldehyde in a dialysis unit 

who had marked reductions in peak expiratory flow rates 

(PEF) when challenged with formaldehyde vapor. The 

responses in these cases were of the delayed type. 

Bronchial provocation challenge with 2 ppm formaldehyde 

gas of 230 individuals with asthma-like symptoms who 

had been exposed previously to formaldehyde found 3 subjects 

who had immediate responses of a more than 20% 

drop in PEF and 4 additional subjects with delayed 

responses characterized by a PEF decrease of 20% or 

more. 41 Because high levels of formaldehyde (2 ppm) were 

used for the provocation challenge, the effects seen were 

thought to have resulted from nonspecific irritant reactions. 

Studies of adult asthmatics exposed to formaldehyde have 

not found important decreases in airway flow. Bronchial 

provocation challenges of 9 asthmatics with 3 ppm 

formaldehyde for more than 30 minutes and a similar challenge 

of 15 asthmatics with 2 ppm formaldehyde failed to 

show significant changes in expiratory flow. 46,55 Bronchial 

challenge of 13 patients with suspected formaldehyderelated 

asthma with concentrations of up to 3 ppm failed 

to show significant decreases in expiratory flow. 16 A study

of PEF in medical students exposed to an average of 0.7 

ppm formaldehyde in an anatomy laboratory class found a 

small but significant decline during the course of the 

semester that reversed when the course was completed and 

exposure ceased. 28 Pre- and postshift spirometry in workers 

exposed to formaldehyde from particle board or molding 

operations showed a small but significant decline in 

forced expiratory flow at 25% to 75% of forced vital 

capacity (this is a measure of small airway flow) in workers 

exposed to 0.5–1 ppm formaldehyde compared to a 

control group. 23 No permanent reduction in flow was 

found. In summary, provocation challenges with formaldehyde 

in concentrations of up to 3 ppm do not produce significant 

bronchoconstriction in small numbers of volunteer 

asthmatics, but studies of larger groups of presumably normal 

subjects have shown small decreases in air flow that 

appear to be reversible. Formaldehyde has been reported to 

aggravate pediatric asthma. 11 

One well-documented case of formaldehyde asthma in 

a nurse was confirmed by bronchial provocation challenge 

with 3 ppm formaldehyde for 5 minutes, producing 

a late asthmatic reaction with a decrease of more 

than 20% in PEF. 53 Immunologic testing for antibodies 

to formaldehyde-human serum albumin has been suggested 

as a way to detect IgE and IgG antibodies in 

persons allergic to formaldehyde 17 as well as in occupationally 

exposed persons, 12 but the utility of this test in 

evaluating formaldehyde-induced asthma is currently 

unknown. Formaldehyde-related asthma appears to be a 

rare condition. 


▼ Chronic Effects of Formaldehyde Exposure 

Area affected Effects 

Skin Sensitization and contact dermatitis 

Nose Dysplasia, squamous metaplasia 

Lungs Bronchospasm, pneumonitis 

Blood Possible chromosomal alteration 



Formaldehyde was found to cause nasal cancer in rats 

exposed to very high doses (14 ppm) by inhalation for several 

weeks. 1,27 These studies showed that the response was 

nonlinear, and excess nasal cancers did not develop at 

lower doses. This finding led the U.S. Consumer Product 

Safety Commission to ban the use of urea-formaldehyde 

insulation in homes. 37 It has been suggested that formaldehyde 

is a rodent carcinogen because at high concentrations 

it causes cell death and induces cell proliferation and mitogenesis, 

35 which in themselves are probably tumor promoters. 

2 Mice and hamsters do not develop cancers from 

formaldehyde. 29 Formaldehyde is unique as a suspected 

carcinogen in that it is present in normal tissue. 

The epidemiologic evidence for the carcinogenicity of 

formaldehyde in humans is quite weak, and results of more 

than 30 studies have not been consistent. 6,34,37,51 Most 

studies have involved occupationally exposed groups, and 

findings in the various groups have differed. Excess numbers 

of nasal cancer have not been found in populations 

exposed to formaldehyde except in those also exposed to 

wood dust, which itself is associated with nasal cancer. 6,34 

Nasopharyngeal cancer was associated with formaldehyde 

exposure 6 in one study of industrial workers. However, 

since major risk factors for nasopharyngeal cancer are 

known to be tobacco and alcohol use, this finding could be 

the result of these confounding factors. Lung cancer has 

not been found in excess in industrial workers or professionals 

exposed to formaldehyde. 6,34 

There is some limited experimental evidence indicating 

that formaldehyde gas may cause precancerous changes in 

humans. Chronic exposure to formaldehyde at levels of 

0.5–2 ppm has been associated with squamous metaplasia 

of human nasal epithelium 9,13 and with chromosomal alteration 

of nasal cells in the form of micronuclei. 3 Chromosomal 

alterations in white blood cells were reported in a 

study of student morticians. 10 However, this finding was 

not duplicated in studies of medical students taking gross 

anatomy courses. 52 DNA-protein cross-links in peripheral 

white blood cells were reported to be increased in


anatomists and pathologists exposed to formaldehyde compared 

to control subjects. 48 The clinical significance of 

these changes is currently not known. 

The International Agency for Research on Cancer 

reviewed the carcinogenicity of formaldehyde in 1994. 24 

The agency concluded that there was sufficient evidence in 

experimental animals and limited evidence in humans and 

classified formaldehyde as probably carcinogenic to 

humans. 

Multiple Substance Exposure 

When formaldehyde is present together with other potential 

irritants, such as those in smog, the smell threshold 

may be lowered to 0.01 ppm and irritant effects may be 

found at levels as low as 0.05 ppm. Formaldehyde in 

aerosols increases airway resistance in guinea pigs compared 

to similar amounts of formaldehyde present as gas. 29 



BIOCHEMISTRY 

Formaldehyde is water soluble and is thus readily absorbed 

via inhalation or ingestion. During nasal breathing, almost 

all inhaled formaldehyde will be deposited on the mucous 

layer of the nasal mucosa, while oral breathing will allow 

it to deposit in the lower respiratory tract. 29 Formaldehyde 

is a normal metabolite and is involved in the transfer of 

methyl groups in dealkylation. Exogenous and endogenous 

formaldehyde is metabolized in a similar manner and is 

eliminated from the blood in 1–2 minutes. 38 Formaldehyde 

is oxidized to formic acid in erythrocytes and in the liver. 

The formic acid can then be oxidized to carbon dioxide or 

excreted in the urine. The oxidation of formaldehyde to 

carbon dioxide is decreased by ingestion of ethanol. In 

monkeys, metabolism of formaldehyde is decreased by 

folic acid deficiency. 38 

Formaldehyde is highly reactive and readily forms 

methylol adducts with the amines in nucleic acids and proteins. 

Formaldehyde also forms cross-links in proteins and 

nucleic acids by joining amines to its carbonyl group. In 

living organisms, these cross-links are unstable due to 

repair mechanisms such as aldehyde dehydrogenases and 

oxidases. 29 

DIAGNOSIS 

Adverse health effects secondary to formaldehyde exposure 

may occur from ingestion, inhalation, or skin exposure. 

Because individuals vary in their reporting of irritant 

effects and because there may be individual variation in 

sensitivity to formaldehyde, it is difficult to set effective 

exposure limits. 

Diagnosis of acute irritant reactions or overdoses may be 

made from the history of exposure. There are no peculiar 

physical features of skin or pulmonary disorders due to 

formaldehyde exposure. 

There are no laboratory tests specific for formaldehyde 

exposure. Because formaldehyde is metabolized in minutes 

and because small quantities are present normally,

formaldehyde levels in blood cannot be used to measure 

exposure. Some metabolized formaldehyde is excreted as 

urinary formate. Methanol, acetone, and substances that are 

metabolized to form one-carbon products, such as pectin in 

apples, are also metabolized to formate and contribute to 

urinary formate excretion. Because urinary formate excretion 

has multiple sources, it is not useful for assessing 

formaldehyde exposure. 7 Exposure to formaldehyde by 

inhalation may be estimated from air samples in the 

breathing zone of the individual. 7 There is no quantitative 

test to assess formaldehyde absorption through the skin or 

by ingestion. 

Patch testing with nonirritating (< 2%) solutions of 

formaldehyde can be used to test for delayed hypersensitivity. 

4 The clinical usefulness of measuring IgE or IgG 

antibody to formaldehyde-protein complexes is currently 

unknown. 4,17 

Diagnostic Dilemmas 

The clinical evaluation of the patient who develops asthma 

following exposure to formaldehyde presents the clinician 

with the dilemma of establishing whether the asthma arose 

de novo after the exposure or whether it is preexisting 

asthma that has been quiescent until an attack was triggered 

by the formaldehyde. Bronchial provocation challenge 

testing may be useful in establishing the degree of 

airway responsiveness. A drop in forced expiratory flow or 

forced expiratory volume in 1 second of 20% or more after 

challenge may help to support, but not confirm, the diagnosis 

of formaldehyde-related asthma. 

Patients who report irritant reactions to low levels of 

formaldehyde that do not bother other household members 

or other coworkers may be difficult to evaluate. The complaints 

in this setting are usually solely subjective, and 

there is no diagnostic test to determine the presence of 

ocular irritation, headaches, and other “annoyance” reactions. 

Measurement of air levels of formaldehyde may be 

helpful in an attempt to quantify exposure. Reduction of 


exposure by better ventilation, personal protective equipment, 

or assignment to another work area may alleviate 

symptoms. 

MANAGEMENT AND TREATMENT 

Irritant and allergic-type reactions that may be related to 

formaldehyde should be managed by removal from exposure 

and symptomatic treatment. Acute splash exposures to 

the eye should be immediately treated by washing with 

water. 

CONSULTATION, REFERRAL, 

AND FOLLOW-UP CARE 

Consultation regarding possible formaldehyde-related contact 

dermatitis may be obtained from a dermatologist or 

allergist. Patients with possible formaldehyde-related 

asthma should be evaluated by a pulmonologist or occupational 

medicine specialist with experience in bronchial 

provocation testing. 

There are no specific medications or therapies for 

formaldehyde-related medical complaints. Follow-up care 

should be aimed at reducing or preventing future exposures. 

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