視床前核の手術

Anterior and Dorsomedial Thalamotomy for the Treatment of Aggressive Symptoms in Oligophrenic Children

I．緒言

　視床前核手術というのは、もともと帯状回前部手術と同じ目的で，精神分裂病などの患者の不安除去を企図して行なわれた（Spiegen ＆ Wycis，1953^43）；Rondepierre ＆ Talairach，1953^34）。したがつて、視床前核手術について記載するには当然帯状回手術，前頭葉ロボトミー等，いわゆる人格変化，感情変化を中心とした鎮静的脳手術（Seomative neurosurgery）（佐野）^37）の一環として述べる必要がある。

　鎮静的脳手術については，佐野^37）の詳細な報告があるが，一般に興奮性白痴，非行，狂暴者を緩和ならしめる目的で，脳になんらかの侵襲を加え病的改善をはかろうとする試みは古くから種々試みられている。しかし，如何なる手術術式がもつとも効果的かとなるといまだ定説はない，その主な理由は、この方面の手術は術前の精神機能。ことに知能の発達程度により手術効果がいちじるしくことなる（中田）^26）27）ことによると思われるが、同時に現今では種々の薬剤に，よりある程度までは鎮静的効果が得られるようになつてきたことにもよると思われる。

　Operative interventions in oligophrenic childrenwith aggressive symptoms have usually consistedof frontal lobotomy or lobectomy, anterior cingulectomy, ligation of the anterior cerebral artery, destruction of the medial thalamic nuclei, amygdaloidectomy, or a combination of some of these procedures.

　In this report, lesions were made stereotaxicallyin the anterior and dorsomedial thalamic nuclei onboth sides in 5 cases. Except 1 case with tuberoussclerosis in which no development of intelligencewas recognizable, there was considerable effect infollow-up study of 2. 5-4 years in 4 cases. According to Schaltenbrand and Bailey's stereotaxicatlas, the anterior main thalamic nucleus, whichconnects with the anterior part of the cingulate gyrus, and the anterior nucleus of the medial fibrosus,which projects to the gyros rectus of the corticalsurface (area 11), are situated in the same verticalplaneof Fp 1.5; that is 1.5mm posterior of themidcommissural point. Moreover, both nuclei liebetween the nuclei cucullaris and the oral mediallamella, both of which belong to the socalled diffuseprojection thalamic system. Considering these anatomical relations, it was considered that both nucleiwould be stereotaxically destroyed at the same timeby temporal approach. Although it is not certain thatboth nuclei have correctly been destroyed or not, our results seem to be the most effective, as compared with those of other procedures, such asfrontal lobotomy (18 cases), cervical arterio-venousanastomosis (3 cases) and anterior cingulectomy(6 cases) which were performed for 15 years.

　Since there are controversial opinions as to theclassification of thalamic nuclei, Hassler's classification which has been used in Schaltenbrand andBailey's stereotaxic atlas, was compared withothers, and the reasons why we began to try thisoperation were discussed.