【作者】 杨爱萍；

【导师】 陈群；

【作者基本信息】 广州中医药大学 ， 中医诊断学， 2009， 博士

【摘要】 原发性痛经是妇科常见病、因其高发病率及治疗棘手,给女性的身心健康和工作学习带来了严重的影响,引起人们的关注,现代研究认为气血运行不畅是其最主要的病理基础。舌诊是望诊的一个重要内容,通过望舌,可以了解机体的生理功能和病理变化,瘀血舌象的出现标志着体内瘀血的存在。鉴于原发性痛经的发病机制多与血瘀有关,因此,选择临床常见的、有一定特点的原发性痛经疾病作为切入点,通过文献研究、临床研究、实验研究、舌象图像分析等方法,探讨原发性痛经疾病的症状及证型分布特点,进一步分析原发性痛经瘀血舌象的舌象特征、形成机制,并初步建立了原发性痛经疾病瘀血舌象特征信息库,以求实现瘀血舌象诊断的信息化、数字化、标准化。论文分为六个部分:第一部分研究背景系统地整理和研究了古今中外与原发性痛经疾病及瘀血舌象相关的文献。古代医家对于瘀血舌的舌象特征论述,内容较多,但重点集中在青舌、紫舌、蓝舌、瘀点舌及舌下络脉的改变的描述上,现代研究多从临床研究、计算机识别技术和实验指标方面进行论述。原发性痛经疾病的中医研究从病因病机、辨证分型的角度进行综述,发现原发性痛经属寒者居多,无瘀者绝少,辨证多责之于寒凝和血瘀。其主要病机是多种病因最终造成气血运行不畅,气机阻滞,不通则痛。此病证型以气滞血瘀型、寒凝气滞型较多见,虚证热证者少。有关原发性痛经的舌诊研究,主要从临床和实验研究两方面探讨,但鲜有原发性痛经瘀血舌象的报导。第二部分文献研究研究目的:通过文献检索,分析原发性痛经患者年龄、病程、婚姻状况、疼痛特点及其中医常见证候类型。研究对象:中文科技期刊数据库（维普）检索有关原发性痛经中医论述方面的文献。研究方法:将文献中病例数,证型类别和频次,年龄,病程,婚姻状况,痛经疼痛时间、部位、性质、经色,用EXCEL软件录入后建立数据库,统计方法采用描述性分析方法。研究结果与结论:原发性痛经患者多见于年轻未婚女性,经期或前后小腹部或腰部疼痛难忍,且疼痛多于经前或经期明显,痛经的产生有虚有实,在实证病例中气滞血瘀和寒湿凝滞证型比例最大,虚证中,以气血亏虚和肝肾不足为主,然而虚实之证均不离乎滞和瘀,瘀血内阻贯穿于此病的整个发病过程,是原发性痛经疾病的主要病机。第三部分临床研究研究目的:探讨原发性痛经疾病的症状、证候及舌象特征。研究对象:100例原发性痛经患者。研究方法:采用前瞻性研究方法。研究结果与结论:原发性痛经疾病好发于青年未婚女子,与遗传等有一定的关系。原发性痛经的疼痛多出现的时间多于经前与经期,且与证型有关;其证型分布与病程也密切相关;疼痛部位多见于小腹部;原发性痛经的中医证型主要有寒湿凝滞、气滞血瘀、气血亏虚和肝肾亏虚等,瘀血内阻是原发性痛经疾病发病过程中非常重要的因素。原发性痛经舌象的表现瘀血舌象所占比重较大,特别是淡白暗舌;从舌下络脉研究发现原发性痛经瘀血舌患者多数存在严重的舌下络脉异常,表明舌下络脉的异常变化是原发性痛经瘀血舌象的一个重要表现特征。第四部分实验研究研究目的:从分子水平探讨原发性痛经瘀血舌象形成的病理机制。研究对象:在临床研究所纳入病例中,选择22例原发性痛经疾病瘀血舌患者、19例原发性痛经非瘀血舌患者、20例健康人。研究方法:空腹静脉采血检测以下指标:（1）血清抗β₂-糖蛋白Ⅰ抗体（β₂-GP1 Ab IgG）水平。（2）血小板活化因子（PAF）。（3）血小板活化因子乙酰水解酶（PAF-AH）活性。研究结果与结论:1、研究结果1.1原发性痛经瘀血舌患者的外周血中β₂-GP1 Ab IgG值显著高于非瘀血舌组及健康对照组;而非瘀血舌组与健康对照组比较,无统计学差异;各证型组间的β₂-GP1 Ab IgG浓度比较,差异无显著性（P＞0.05）。1.2原发性痛经瘀血舌组的PAF值水平高于非瘀血舌组及健康对照组;而非瘀血舌组与健康对照组比较,无统计学差异;各证型组间的PAF值水平浓度比较,差异无显著性（P＞0.05）。1.3原发性痛经疾病三组经比较,差异有统计学意义（P＜0.01）。瘀血舌组的PAFA值水平低于非瘀血舌组及健康对照组;非瘀血舌组与健康对照组比较,差异无统计学意义（P＞0.05）。各证型组间的PAFA水平比较,差异无显著性（P＞0.05）。2、结论2.1β₂-GP1 Ab IgG是原发性痛经疾病瘀血舌象形成的一种危险因子β₂-GP1 Ab IgG可能参与了原发性痛经疾病的形成过程,特别可能是与原发性痛经疾病瘀血舌象患者发病机制有关,原发性痛经疾病瘀血舌象与β₂-GP1 AIgG关系密切,抗β₂GP1抗体也可能是原发性痛经疾病的一种重要危险因子。2.2 PAF是原发性痛经瘀血舌象形成的重要病理基础PAF可能是原发性痛经疾病瘀血舌象患者的高凝状态形成的重要因素之一。原发性痛经疾病瘀血舌象患者产生的PAF可能会从多个途径来促进其高凝状态的形成,具体途径我们不得而知,但毫无疑问的是血小板激活会促进血小板粘附、聚集,使血流缓慢,组织缺氧反映于舌,而成为瘀血舌象。2.3 PAF-AH是原发性痛经瘀血舌象形成的重要环节我们推测PAF-AH的活性不足可能是原发性痛经瘀血患者发生、发展的一个影响因素,其活性水平在进行原发性痛经瘀血舌象患者病情变化及预后判断时可能具有一定的参考意义。总之,原发性痛经瘀血舌象患者外周血中β₂-GP1 Ab IgG浓度升高、PAF活性也明显增高、PAF-AH活性明显降低。我们考虑PAF-AH与PAF的失衡在原发性痛经瘀血舌象的发生机制中可能有一定作用,但这三者之间有无相关性,参照资料报导特异性β₁糖蛋白是血浆PAF-AH转录所必需的物质,我们相信它们可能通过更复杂的关系相互影响,具体过程更有待于今后的研究中进行深入。第五部分图像分割研究目的:开展图像数字化、标准化研究。研究方法:应用“基于最短路径的医学舌苔图像分割方法”开展舌图像分割,进行舌象的分析研究。效果:图像的分割是计算机图像处理的一个经典课题,是开展舌象图像处理最关键也是最先进行的一步。本研究应用“基于最短路径的医学舌苔图像分割方法”对图像进行分割,取得较令人满意的效果,了解了舌苔及舌下络脉状况。推进了原发性痛经舌象的临床诊断标准数字化,由于属于早期探索研究,将作为课题组下一步研究的方向。第六部分结语本课题的创新性:1、以原发性痛经疾病为切入点开展其临床症状规律、证型分布及舌象研究,特别是瘀血舌象的研究,通过挖掘有效数据,了解原发性痛经疾病瘀血舌象的临床分布规律及形成机理。2、应用“基于最短路径的医学舌苔图像分割方法”对图像进行分割,既可让分析更直观,又可保留原图像所有的信息,提高分析的精确度。3、拓宽了原发性痛经疾病的研究思路,同时也为建立原发性痛经疾病瘀血舌象的诊断标准及标准的顺利实施探索了一种重要的研究方法。更多还原

【Abstract】 Primary dysmenorrhea is a common disorder in women with a high incidence and difficult to be treated.It affects women’s everyday life and even their work,so it is greatly concerned.Modern researches have found that blood stasis is the critical pathologic reason.Tongue,an important part of inspection in these researches, indicates physiological functions and pathological mechanisms.The tongue blood stasis（TBS） is very common in clinics and is of great clinical significance for the diagnosis of the body blood stasis syndrome.Because of the relevance between the blood stasis and primary dysmenorrhea,Primary dysmenorrhea is taken as the research object in the present study;the symptom and distribution of TCM syndromes of primary dysmenorrhea,the clinical characteristics and the mechanism of formation of TBS were be discussed;and the characteristic database of TBS was roughly established by the methods of literature research,clinical research,experimental study, image analysis of the tongue and so on,in order to realize the informationization, digitization,standardization of the diagnosis of TBS.The dissertation is divided into six parts.Part 1 Research BackgroundThe related literature,which were correlated with primary dysmenorrhea and TBS of all times and in all countries were reorganized and studied systematically.The ancient Chinese phisicians had done many researches about blood stasis tongue image, especially about the bluish tongue,the purplish tongue,the petechia tongue, ecchymosis on the tongue,and changes of sublingual meridians.Doctors in the modern age have studied TBS from many angles such as clinical observation, experimental study,automatic recognition and analysis by computer,etc.TCM reviews on primary dysmenorrhea indicated that cold syndrome mostly appear among the patients suffering from primary dysmenorrhea,and very few patients were without blood stasis,so distribution of TCM syndromes of primary dysmenorrhea were high frequency of cold and blood stasis syndrome.Its formation was a combination of many factors,with blood stasis as its main pathogenesis."Stagnancy of both blood and qi syndrome" and "blood stasis due to cold syndrome" mostly appear among the patients suffering from primary dysmenorrhea, but "deficiency syndrome" and "heat sydrome" seldom appear among those patient.Diagnosis of the tongues of patients with primary dysmenorrhea were mostly studied from clinical observation and experimental study,but there were few reports on tongue images of patients with primary dysmenorrhea.Part 2 Literature ResearchObjective:to explore primary dysmenorrhea patients’ ages,courses of diseases, marriages,clinical characteristics of pain and syndromes of by literature retrieval.Objects:literatures of primary dysmenorrhea in TCM in VIP informationMethod:to put cases,syndrome types,ages,courses of disease,marriages,clinical characteristics,times and parts of pain into excel tables and establish database.Results and Conclusions:The patients with primary dysmenorrheal were mostly young unmarried women;their main symptoms were pains in the inferior belly and lower back, espically before and during their menstruation.It was clear that the proportions of "Stagnancy of both blood and qi syndrome" and "blood stasis due to cold syndrome" were the highest in excess syndrome,but "deficiency of both blood and qi syndrome" and "deficiency of liver and kidney symdrome" mostly appeared among patients with deficiency syndrome.The stagnation of blood stasis,occurring during the whole pathogenic process,was the main pathogenesis of primary dysmenorrhea.Part 3 Clinical ResearchObjective:to explore the symptoms,syndromes and clinical characteristics of tongues of patients with primary dysmenorrhea.Objects:100 cases with primary dysmenorrhea.Method:The retrospective study was made.Results and Conclusions:The patients with primary dysmenorrhea were mostly young unmarried women.Their diseases were relevant with heredity.Their pains often occurred in the inferior belly,espically before and during their menstruation,and there were relevance between the courses of disease and syndromes,there were four main syndrome types among the 100 patients with primary dysmenorrhea,i.e.,"Stagnancy of both blood and qi syndrome","blood stasis due to cold syndrome","deficiency of both blood and qi syndrome",and "deficiency of liver and kidney symdrome".Stagnation of blood stasis was an important factor to the occurrence of primary dysmenorrhea.Clinical observation showed that most tongue bodies of patients with primary dysmenorrhea manifested tongue blood stasis（TBS）,especially pale darkish tongue.Serious abnormal sublingual meridians also existed in patients with primary dysmenorrhea.Part4 Clinical Experimental StudyObjective:to explore the pathologic mechanism of the tongue of blood stasis of primary dysmenorrhea（TBSD） on the molecular levelObjects:22 cases with TBSD and 19 cases with TNBSD were observed among patients who were selected in the clinical research,and 20 healthy cases were also used.Method:take hemospasia venous blood to examine the following indexes:（1）β2-GP1 Ab IgG（2） platelet activating factor（PAF）（3） platelet-activating factor acetylhydrolase（PAF-AH）Results and Conclusions:1.Results1.1 the contents ofβ₂-GP1 Ab IgG in patients of TBSD were higher than those in patients of TNBSC and healthy cases group,but there were no significant deviation between that in patients of TNBSC and healthy cases group,and there were no significant density deviation ofβ₂-GP1 Ab IgG among these groups（P＞0.05）.1.2 the contents of PAF in patients of TBSD were higher than those in patients of TNBSC and healthy cases group,but there were no significant deviation between in patients of TNBSC and healthy cases group,and there were no significant density deviation of PAF among these groups（P＞0.05）.1.3 the contents of PAF-AH in patients of TBSD were higher than those in patients of TNBSC and healthy cases group（P＜0.01）,but there were no significant deviation between in patients of TNBSC and healthy cases group（P＞0.05）,and there were no significant deviation of PAFA among these groups（P＞0.05）.2.Conclusions2.1β2-GP1 Ab IgG is a risk factor for the formation of TBSDβ2-GP1 Ab IgG’s content levels were related to the formation of primary dysmenorrhea, especially the pathologic mechanism of the tongue blood stasis of patients with primary dysmenorrhea（TBSD）.β2-GP1 Ab IgG is a danger factor in the information of primary dysmenorrhea.2.2PAF is an important pathologic basis of the formation of TBSDContent level of PAF in patients is a important factor in the formation of high thickness in blood of patients with primary dysmenorrhea.These PAF help to form hypercoagulable states through many ways,but the exact ways are unknown now.undoubtedly,platelet activation can enhance platelet adhesion and platelet aggregation,which will slow down coronary flow and cause anoxia,and which will finally cause tongue blood stasis.2.3PAF-AH is an important part of the formation of TBSDIt is concluded that the deficiency of PAF-AH is likely to be an inflectional factor leading to the formation of tongue blood stasis of patients with primary dysmenorrhea.The content level of PAF-AH has great significance in ill states and prognosis of tongue blood stasis of patients with primary dysmenorrhea.Part 5 Image segmentation of TBSDObjective:to explore the digitization,standardization of the diagnosis of TBSDMethod:Study tongue blood stasis of patients with primary dysmenorrhea by "the shortest path based on the medical tongue image segmentation approach".Results and Conclusions:Image segmentation,a classical subject of computer image processing,is the most critical step and very first in tongue image processing.In this study,image segmentation based on "the shortest path based on the medical tongue image segmentation approach" obtained satisfactory results,and made the tongue coating and the sublingual collateral situation be understood.It has advanced the standardization of numbers in clinical diagnosis of tongue images of patients with Primary Dysmenorrhea,and as a result of early exploration and research,It will serve as the direction of further study.Part 6 SummaryThe innovations in this study:1.The present study start from the law of its clinical symptoms,distribution of TCM Syndromes and tongue research of patients with primary dysmenorrhea, particularly tongue blood stasis research.The clinical distribution and formation mechanism of tongue blood stasis of patients with primary dysmenorrheal were understood through analyzing effective data.2.This research has applied image segmentation based on "the shortest path based on the medical tongue image segmentation approach",which can not only be more intuitive,but also can retain all the original image information,and improve the accuracy of the analysis.3.It has not only broaden the approaches of primary dysmenorrhea diseases research,but also explored important research methods that can help to establish diagnostic standards of tongue of blood stasis of patients with primary dysmenorrhea and found a way of applying that smoothly.更多还原