“Thyroid Steal”—A Historical Approach to Thyroid Surgery for Graves' Disease

Dear Editor:

The term “thyroid steal” is important in the history of thyroidology (1) and refers to the method used by George W. Crile in 1905 to prepare patients for thyroidectomy for Graves' disease. It describes that the patients were anesthetized in their hospital room without knowing that their thyroid was going to be removed surgically—hence, the thyroid was “stolen.” However, the term has been usurped by the term “thyroid steal syndrome” in which transient cerebral ischemia is produced by the thyroid deviating blood from the cerebral circulation or if the cerebral circulation is compromised by a goiter (1). The purpose of “stealing the thyroid” was to minimize stress to the patient, thereby avoiding thyroid storm pre-, intra-, and postoperatively in order to decrease mortality.

In the literature, different terms have been used for “thyroid steal”: stealing upon the thyroid, stealing operation, stealing the goiter, stealing the toxic goiter, and stealing the thyroid. Subsequently, the term “thyroid steal” was adopted to describe the procedure.

George W. Crile enunciated the kinetic theory of shock and the development of the shockless operation (2), and he introduced the term anoci-association to prevent kinetic shock. Although he never used the term “thyroid steal,” his description of the procedure published in 1911 (3) and 1915 included the method in which the thyroid was “stolen” and was published prior to the development of antithyroidal drugs and radioactive iodine in the 1940s.

If a surgery was planned, patients with Graves' disease were admitted without mentioning an operation. The preoperative routine was of primary importance, but the patient was not informed about the exact day of the operation. The operating-room clothes were usually put on the day after admission. At 8:00am each morning, a hypodermic injection of sterile water was given. At 9:00am each morning, the anesthetist would take a nitrous oxide–oxygen machine to the bedside and explain that the patient was to have some oxygen to help the heart. On the morning of the operation, an injection of morphine and atropine was substituted for the sterile water, and at the usual time, the anesthetist administered the nitrous-oxide anesthetic. Surgery was carried out in the patient's bed or in the operating room. In more severe cases, the thyroid activity was diminished by a preliminary ligation of the superior thyroid artery performed in the patient's bed under nitrous-oxide analgesia and local anesthesia. It is uncertain how commonly “thyroid steal” was utilized by other surgeons such as Dunhill, Mayo, and Halsted, but it appears not to have been routinely employed.

Various anesthetic agents apart from nitrous oxide have subsequently been utilized (avertin in amylene hydrate rectally, intravenous Pentothal sodium, supplementation with spinal anesthetic, and intravenous or oral amytal) in the preparation of the patient for “thyroid steal.”

In 1949, Mousel and Coakley (4) noted that there may still be occasion for “stealing” of the goiter. For example, in 1962, one of us (J.P.) was the anesthetist for a patient undergoing “thyroid steal” for Graves' disease. The patient was unable to take antithyroidal medication (beta blockers were not available at that time, and radioiodine was not deemed appropriate). The patient was told that treatment with thyroid-calming medicine given rectally was needed during four days prior to the thyroidectomy. On the third day, the patient was given a barbiturate enema and then taken to the operating theater, and a successful thyroidectomy was undertaken.