Surgical and Radiologic Anatomy

, Volume 33, Issue 4, pp 359–363

Is Thiel’s embalming method widely known? A world survey about its use

  • Mehdi Benkhadra
  • Julien Gérard
  • Denis Genelot
  • Pierre Trouilloud
  • Claude Girard
  • Friedrich Anderhuber
  • Georg Feigl
Original Article

DOI: 10.1007/s00276-010-0705-6

Cite this article as:
Benkhadra, M., Gérard, J., Genelot, D. et al. Surg Radiol Anat (2011) 33: 359. doi:10.1007/s00276-010-0705-6

Abstract

Introduction

Thiel’s embalming technique, first described by Thiel in 1992, conserves texture and colour in cadavers close to that observed in the living. It would appear that few anatomy laboratories use this method, and literature describing its use worldwide is sparse. The aim of our study was to conduct a worldwide survey on the use of this method.

Methods

A questionnaire was sent out by mail to 311 anatomy laboratories or institutes across the five continents. There were six multiple choice questions to assess the level of awareness of Thiel’s method, the frequency of its use among respondent institutions, the most frequently used solutions for conservation of cadavers and perceived obstacles to the use of Thiel’s technique.

Results

109/311 (35%) centres replied to the questionnaire; 56% of centres had previously heard of Thiel’s technique, but only 11 centres (10% of respondents) used it regularly, and all of these were in Europe. Formalin remains the most widely used conservation solution around the world.

Conclusions

Thiel’s embalming technique is not widely known, and therefore, little used. The main obstacle to its wider use is likely the language barrier, since most of the publications describing Thiel’s method are in German, which is not widely spoken outside of a few European countries.

Keywords

Worldwise use Email survey Thiel’s embalming method 

Introduction

Thiel’s embalming technique was developed by Pr. Walter Thiel in Austria over a period of several years, leading to a seminal publication in 1992 [14, 15, 16]. The method consists in intravascular embalming using a solution combining several chemicals, whose exact composition is given in Thiel’s original publication. Several reports have shown that cadavers conserved using this method present a texture and colour very close to that of living individuals, and several applications in areas such as surgery, echography, regional anesthesia and anaesthesiology research on the airways have been described [1, 4, 5, 6, 7, 8, 10, 13, 18, 19]. Awareness of Thiel’s method and the frequency of its use seem to be limited around the world, but to the best of our knowledge, no survey has ever been performed to evaluate the use of technique in the world. The aim of our study was to carry out a worldwide survey of anatomy laboratories and institutes to quantify the rate of use of Thiel’s embalming technique.

Methods

Worldwide survey conducted by email.

Constitution of a world-scale mailing list

We searched the freely accessible internet encyclopaedia « Wikipedia », using the search terms “List of the countries of the world” and “List of medical schools” to compile a list comprising a maximum of universities and medical schools per city, country and continent. An Excel spreadsheet (Microsoft Corporation) was used to collate the search results. A large proportion of contact email addresses were obtained from the online registries of the American Association of Clinical Anatomists (AACA) and the European Association of Clinical Anatomists (EACA). To complete the list of email contacts, we searched the individual websites of each faculty or university to identify the anatomy laboratory, using the following keywords: anatomy, anatomy department, anatomy laboratory, anatomia, anatomja. In a large number of cases, this keyword search directed us to the website of the relevant anatomy laboratory/department.

Using these search methods, we compiled a first list of approximately 900 universities and faculties through Wikipedia, but we were only able to identify an email address for 339 anatomy laboratories and institutes.

Contents of the questionnaire

For each anatomy laboratory or institute, we recorded one email address, and one questionnaire was sent to this address.

The questionnaire comprised the following questions:
  • Question 1 Have you already heard about Thiel’s embalming technique? Yes/No

  • Question 2 If you have answered “Yes” to question 1, what is the appropriate(s) sentence(s) in the following?
    • I have already seen or/and worked on a cadaver embalmed according to Thiel’s method

    • I have already embalmed a cadaver according to Thiel’s technique

    • I have only heard or read about this technique but I have never performed this technique and I have never work on this kind of cadavers

  • Question 3 Do you use this technique in your laboratory or institution?
    • If yes, for how many times?

    • No

    • We have the project to perform this method in the future

  • Question4 If you do not use Thiel’s embalming technique, what are the two principal reason(s)?
    • I do not know this technique

    • I have heard about this technique but I do not know how to perform it

    • It is very expensive

    • It requires materials we do not have

    • We do not want to use this technique because we do not like to work on this kind of cadavers

  • Question 5 What is the embalming technique most often used in your institution? We do not expect you to give us your embalming secrets, but only the main chemical product you use:
    • Formaldehyde

    • Chloride of Zinc

    • Phenol

    • Jorez

    • Freeze (−20 °C)

    • Other

  • Question 6 If you have already worked on cadaver preserved according to Thiel’s technique, what are the positive and negative aspects do you find in this kind of method?

Reminder emails were sent out 1 and 3 months after the initial mail to all laboratories or institutes who had not yet replied.

Statistical analysis

The analysis of all data is purely descriptive. No statistical tests were performed.

Results

The survey was carried out between July and October 2009. Among the 339 emails initially sent out, 29 bounced back because of inaccurate email addresses or links.

Response rate

Among the remaining 311 centres, 109 responded and filled out the questionnaire in its entirety (35% response rate). This rate varied considerably between continents, with a 58% response rate (74/127 centres) in Europe, 15% (16/103) in America, 31% (10/32) in Asia, 33% (2/6) in Africa and 41% (7/17) in Oceania.

Responses to question 1

78% of European centres had previously heard of Thiel’s embalming technique, 10% in America, 7% in Asia, 2% in Africa and 3% in Oceania, making an overall total of 56%.

Responses to question 2

Among the (mainly European) centres who were aware of Thiel’s method, 43% declared that they had practical experience of Thiel’s method (dissection and/or embalming), whereas the remaining 57% had only theoretical knowledge (congresses, medical literature).

Responses to question 3

Only 11 centres (Fig. 1) use actually perform Thiel’s embalming (not counting Graz in Austria, where the technique was developed, and Dijon, France, principal investigating centre in this survey), and all are situated in Europe. On average, they have been using this technique for the last 6.75 years. Among centres that do not use Thiel’s method, 12 (located in France, the UK, Germany, Canada, Hong Kong, Nigeria and Australia) plan to introduce it in the future.
Fig. 1

Map of Europe showing the five countries that use Thiel’s embalming technique, according to the results of our study

Responses to question 4: obstacles to the use of Thiel’s method

The main limiting factor contributing to the restricted use of Thiel’s technique is the lack of awareness of its existence, with almost 47% declaring that they did not know of this technique, a result that is coherent with the answers given to question 1. The second most frequently cited obstacle (26%) is the lack of knowledge about the practical details of how to perform Thiel’s embalming.

Unavailable material and the too complex nature of the technique were less frequently cited, with, respectively, 11 and 12% of responses. Last, eight centres (7%) reported they did not use this technique, for it did not meet their requirements.

Responses to question 5: solutions used for embalming

The most widely used product in the world is formaldehyde, which is used in almost 87% of centres, and consistently across the five continents: 84% in Europe, 87% in America and 100% in the other three continents.

In joint second position were phenol and freezing, which are used equally frequently, but distributed very differently across respondent centres. Phenol is used in all continents except Africa, mainly in America (62.5%), followed by Oceania (28.6%), Asia (20%) and last Europe (16.2%).

As regards freezing, the distribution is inversed, with more frequent use in Europe (32.4%), 14.3% in Oceania and only 6.2% in America.

Use of Jorez’ technique and chloride of zinc was rarely reported, and almost all reported use was in Europe.

Number of chemical products used

55% of respondent centres reported that they used only one embalming technique (52% in Europe, 37% in America, 80% in Asia, 100% in Africa and 71% in Oceania), and this was mainly formol. Two techniques were used in 42% of centres (28.4% in Europe, 43.7% in America, 14% in Oceania), while 3 different solutions were used in 14.7% of centres (17% in Europe, 12% in America and 14% in Oceania). Two centres in Europe used four methods.

Among the 11 centres that reported using Thiel’s method, only two used it exclusively. The other nine centres all used 1, 2 or even 3 other techniques, mainly formaldehyde (6/11) and freezing (5/11).

Responses to question 6

The reported advantages of Thiel’s method highlight the life-like nature of Thiel preserved cadavers, particularly as regards texture, colour, mobility and flexibility of the tissues and components as compared with other techniques. Thiel’s technique preserves a realism that is almost perfect, and which is ideal not only for surgical teaching programmes, particularly orthopaedic and plastic surgery, but also for teaching of anatomy.

The negative aspects of Thiel’s method reported in response to our questionnaire include the high cost (material, chemical products), the aspect of the skin, the unsuitability for anatomical dissection in the context of teaching and the long preparation time. Certain soft tissues sometimes have a gelatinous aspect with this method. The joints can often be filled with fluid. In addition, certain major organs such as the brain and the bone marrow are consistently badly preserved. Last, there can be signs of distal mummification.

Discussion

Email is increasingly used as a means of conducting surveys [2, 11, 17]. It is inexpensive (no envelopes or stamps required), extremely quick (almost instantaneous transmission of the messages), simple to set up, and not too tedious. In the case of our study, the main difficulty lay in the compilation of the mailing list, as we aimed to be as exhaustive as possible. The complete list can be provided on request to any colleague interested in conducting a worldwide survey among anatomy centres. In our study, the overall response rate was 35%, which is quite acceptable according to Lirk et al. [12]. Indeed, Hazard Munro [9] hypothesises that the acceptable minimum response rate is a function of the number of questions in the questionnaire, and should be at least ten times the number of questions. In the case of our study, the target number of responses was therefore 60, and we received 109 in total. Although Munro’s calculations applied to questionnaires sent out by post, whereas ours was sent out by email, the conditions can be considered to be the same.

The time period selected for our study presents certain advantages and disadvantages. As the survey was sent out over the summer months, the vacation period could be partially responsible for the high rate of non-response. However, we chose this period on purpose, since potential participants often have more time at their disposal for this type of questionnaire outside the academic year, and second, since follow-up reminder emails were sent out at 1 and 3 months, we considered that contact would be made at one time or another with all recipients of the original email.

The majority of respondent centres were European (approximately 67%). The response rate was lower in the centres in America, Africa, Asia and Oceania, but this is not ground enough to believe that the respondents were not representative of their respective continents. Nonetheless, caution is required in the interpretation of the results from these latter continents, in view of the lower number of respondent centres. On the other hand, a representation of the data obtained for Europe makes it possible to ascertain that the spread is quite representative, conferring a certain power to these observations.

Our results show that about 78% of European anatomists know of Thiel’s embalming technique, particularly in German-speaking countries, but less than 10% are aware of this method on other continents. Most (about 57%) of the centres that have heard of this method have never actually had practical experience of it (i.e. have never actually dissected a Thiel embalmed cadaver, or embalmed one themselves using this method). Only 11 centres (not including Graz, Austria, and Dijon, France) actually use this method in routine practice, and they have been using it on average for about 6–7 years, whereas it was first described almost 20 years ago. Formaldehyde remains the most frequently used embalming solution, and was reported to be used in 87% of participating centres. Freezing at −20 °C seems to be mostly used in Europe, while phenol is more common in America. Pressure to avoid errors such as accidental exposure to biological fluids is particularly strong in America, and compels many anatomy laboratories to prefer embalming techniques to freezing. The majority of laboratories that use Thiel’s technique also use one or more other methods, mainly formaldehyde. Thiel’s technique is considered ideal for applications such as surgery (training or teaching), but opinions are divided as regards its usefulness for teaching anatomy. Anatomical dissection for teaching, as opposed to surgical dissection, purely for practising surgical techniques, are the two main activities of anatomy laboratories, and each of these activities is facilitated by a particular method of embalming cadavers. Formaldehyde-based embalming solutions fix and immobilise the tissues, thereby facilitating delicate anatomical dissection procedures, because it is possible to dissect very accurately, like in a sculpture. On the other hand, Thiel’s technique offers almost life-like conditions, like flexibility, and is therefore particularly suited to surgical practice in very realistic conditions, such as when a small nerve is sectioned, it can disappear into the foramen or orifice from which it originated like a snake disappearing down a hole. This flexibility has been considered as the probable consequence of a considerable fragmentation of muscle proteins due to the corrosive effect of Thiel’s solution [3]. Clearly, having both techniques available is advantageous. This could also explain why some centres replied that Thiel’s technique was not suitable for their requirements.

Thiel’s technique is paradoxical in that it is an excellent method, yet not widely known or used among anatomists around the world. Three factors could explain the limited spread of this method. First, the language barrier, since Thiel’s first description of this technique was published in German; second, the cost of the procedure, which is relatively high compared with other methods of conservation and third the infrastructural partially expensive adaptations within the department which have to be done to perform Thiel’s embalming method.

Few reports to date have evaluated Thiel’s technique. There exist only some basic reports explaining the exact details of the embalming procedure, as well as several reports relating the possible applications for Thiel embalmed cadavers in training or research. These latter reports are sparse, but mostly in English [1, 4, 5, 6, 7, 8, 10, 13, 18, 19]. They report the results of various works on Thiel-embalmed cadavers, and consistently report the very life-like conditions that such cadavers proffer. The more fundamental works describing the technique are also few and far between and are mainly published in German [14, 15, 16]. Apart from a few countries in Europe, German is not widely spoken throughout the rest of the world. It is thus easy to understand that the dissemination of Thiel’s method remains limited to a few German-speaking countries. This raises the question of the lingua franca for publications, and the dissemination of non-English work. Thiel’s technique is a prime example of excellent work, with enormous potential, but poorly disseminated. It would be interesting to know how widely developed this technique would be if the original publications describing it had been in English.

The cost of embalming a cadaver using Thiel’s technique is approximately 300 €, as compared with the cost of about 30 € using a more classic, formaldehyde-based technique. Clearly, considerable financial resources are needed to be able to afford routine use of Thiel’s method, which is difficult enough in developed countries, and likely quite impossible in developing countries. There must exist a real need and a strong belief in the superior characteristics of Thiel-embalmed cadavers for its routine use to be envisaged. Learning the technique requires attentive study of Thiel’s original publication, as well as observation and/or practice in centres where the method is frequently used. Indeed, mastering the techniques of embalming cadavers is not only a question of reproducible science, but also of skill and know-how that can only be transmitted through mentored learning.

Conclusion

Our study shows that Thiel’s technique is not widely known among anatomists around the world, and thus, is little used. Formaldehyde remains the most commonly used embalming solution. Two main factors contribute to the limited spread of Thiel’s technique: first, the fact that the original publications describing the method were in German, and second, the high cost compared with other embalming techniques. On a methodological level, our results show that surveys carried out by email procure a relatively satisfactory response rate.

Conflict of interest

No conflict of interest has been declared.

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Mehdi Benkhadra
    • 1
    • 2
    • 4
  • Julien Gérard
    • 2
  • Denis Genelot
    • 2
  • Pierre Trouilloud
    • 2
  • Claude Girard
    • 1
  • Friedrich Anderhuber
    • 3
  • Georg Feigl
    • 3
  1. 1.Department of Anesthesiology and Intensive CareTeaching HospitalDijonFrance
  2. 2.Department of AnatomyINSERM U887, University of BurgundyDijonFrance
  3. 3.Institute of AnatomyMedical UniversityGrazAustria
  4. 4.Laboratoire d’Anatomie, Faculté de MédecineINSERM U887DijonFrance

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