【作者】 陈青红；

【导师】 陈家旭；

【作者基本信息】 北京中医药大学 ， 中医诊断学， 2003， 硕士

【摘要】 前言肝郁证属于脏腑辨证体系中肝胆病证候之一，是肝胆辨证体系中的一个基础性证候。临床上见于多个系统的多种疾病，表现复杂多样。由于肝郁证与情志关系密切，其发病与临床表现涉及生物、心理、社会因素诸多方面，适应临床医学模式转变的需要，近年来对肝郁证的研究备受关注，对于丰富肝郁证与中医关于情志病证研究的理论体系起了很大作用。本研究在查阅大量古今文献的基础上，对肝郁证进行系统研究，阐明其理论渊源与现代发展方向，并采用文献研究同临床研究相结合的方法，拟定肝郁证异病同证中的宏观证候诊断标准；并采用病例对照研究的方法探讨肝郁证患者的植物神经功能状态与情绪状态和血清甲状腺激素的变化规律。本论文包括理论研究与临床研究两部分。1.理论研究1.1肝郁证的源流中医关于肝郁证概念的界定有一个逐渐演变的过程，其概念与理论体系渊源于《内经》的五气之郁，经过《难经》、《伤寒杂病论》的发展，金元医家朱丹溪首倡六郁论，重视“郁”在致病中的重要作用。至此以后，各医家从自己的临床实践的角度出发，不断丰富和发展着肝郁证的有关理论。明·孙一奎第一次明确提出“木郁即肝郁”的观点，将《内经》的“五气之郁”与脏腑郁证联系起来，并在脏腑郁证中重视肝郁的地位和致病作用，开后世着重研究肝郁证的先河。因此，现代研究的肝郁证源于《内经》的五气之郁、金元医家朱丹溪倡导的六郁，亦包含了以后的情志之郁与脏腑郁证的部分内容，历经两千余年的发展。新中国成立后，为适应中医药学学院教育的需要，将肝郁证作为脏腑辨证体系中肝胆病辨证中的一个证候，明确规定情志异常为肝郁证的诱因。1.2肝郁证的病因病机现代对肝郁证的病因病机的认识趋于一致，虽有因病而郁与因郁而病的不同，均认为情志所伤为引起肝郁证的最重要而直接的原因，导致情志损伤的始动因素各不相同，但情志损伤是最重要的中介环节。由于中医学中的情志是五脏精气活动的产物，情志损伤会引起五脏功能异常；同时五脏功能异常时亦会妨碍正常的情志活动而出现郁证。1.3肝郁证的诊断与鉴别诊断肝郁证的诊断要点应抓住肝郁证的特点为情志异常以及由于情志异常影响肝主疏泄调畅气机的正常生理功能，出现肝经经气不利的病机特点，临床上二者不一定全部具备，有时情志异常的出现是一过性的，甚至患者自己没有明显感觉，需仔细询问多能查出情志异常的诱因。肝郁证的鉴别诊断分为肝郁证本身的鉴别以及与其它情志性疾病和情志所伤性证候的鉴别。肝郁证本身的鉴别在于明确患者以肝气郁还是以肝气逆为主，以确定疏肝与平肝的不同治疗原则。肝郁证与其它证候的鉴别点在于肝郁证特征性的情绪异常与肝经经气不利症状的存在。1.4肝郁证的治疗<WP=6>肝郁证的治疗分为药物治疗与非药物治疗两个方面。药物治疗原则以“木郁达之”为主，具体方法与药物的应用视个体差异以及处于不同疾病的不同阶段和有无兼夹证候而有所不同，主方以柴胡疏肝散和逍遥散，或在治疗其它疾病时加以疏肝解郁的药物如川郁金、川楝子、连翘等。非药物治疗主要采用情志疏导以去除致病和加重病情的诱因，或移情易性以预防疾病复发。2.临床研究2.1目的：初步建立异病同证中肝郁证的宏观诊断标准，并对肝郁证患者的植物神经功能状态、情绪状态、血清甲状腺激素含量变化规律进行初步探讨。2.2方法：采用文献研究与临床研究相结合的方法，通过文献研究筛选出频次高的症状体征作为参考诊断标准及症状观察量表，通过两个专家同时诊断作为肝郁证诊断的“金标准”与参考标准对77例患者进行诊断，比较计算符合率、Kappa值。采用病例对照研究的方法考察肝郁证患者植物神经功能与情绪状态，96例研究对象分为肝郁证（49例）、非肝郁证（28例）和正常对照组（19例），所有受试对象一律进行部分物理负荷试验检查和填写焦虑自评量表（SAS）和抑郁自评量表（SDS），植物神经功能检查结果根据文献标准判定，量表结果计算总标准分进行组间比较。对64例研究对象（肝郁证28例，非肝郁证18例，正常对照组18例）空腹抽取肘静脉血进行血清甲状腺激素（T3,T4,RT3,TSH）检测，同时计算T3/RT3比值，比较T3,T4,RT3,TSH，T3/RT3实测值在各组间的差异。组间比较采用卡方检验和方差分析，计量资料以均数( 标准差（X( S）表示，应用SAS6.12和SPSS10.0对其指标进行相关处理。2.3结果：（1）通过文献研究得出本课题组的参考诊断标准：①胸胁作胀或痛；②精神抑郁；③烦躁易怒；④口苦；⑤胸闷；⑥善太息；⑦脉弦。以上七条同时具备四条或四条以上即可诊断。该参考诊断标准与临床专家诊断结果比较，Kappa值为0.71，符合性较好。经肝郁证和非肝郁证临床对照研究，得出以下症状、体征在肝郁证与非肝郁证比较具有显著差别：胸胁作胀或痛、精神抑郁、烦躁易怒、口苦、胸闷、善太息、嗳气、脘腹胀痛、少腹胀闷、腹胀、症状因精神紧张而诱发、咽部异物感、舌红。结合中医理论，以上症状体征加上舌苔薄白、脉弦可作为进一步研究的肝郁证症状条目。（2）肝郁证患者的植物神经功能状态：与非肝郁证和健康对照组比较，肝郁证患者没有表现出具有统计?更多还原

【Abstract】 AimDiagnostic standard of liver-Qi stagnation syndrome of symptoms and signs was set up and its pathophysiological bases were prelimilarily explored in this article.MethodsLiterature research was applied to investigate the frequencies of symptoms and signs about the liver-Qi stagnation syndrome in the classical and modern literatures. Those symptoms and signs with high percentile (95% &75%) in the literatures were listed as diagnostic standard and items included in the symptomological scale. Case-control research method was applied to investigate the clinical cases of liver-Qi stagnation syndrome in order to learn the coincidence rate of made diagnostic standard with the clinical gold standard which is decided by two experts at the same time. 96 cases were included in this investigation: 49 cases of liver-Qi stagnationsyndrome, 28 cases of non-liver-Qi stagnation syndrome and 19 cases of healthy participants.In the meantime, those symptoms and signs with statistical significance compared with non-liver-Qi stagnation syndrome were chosen to simplify the items listed in the scale for profound research in the combination of diseases with syndrome. Physical load examination including reflex of eye-heart, signs of skin stroke, check-up of interval of pulse and blood pressure were done to make sure the function state of vegetation nerve system. Self-rating depression scale and self-rating anxiety scale were adopted to measure the emotional state of patients of liver-Qi stagnation syndrome compared with patients of non-liver-Qi stagnation syndrome and healthy participants. The amount of participants in this investigation was the same as above. Radioimmunoassay and coat-A-count TSH IRMA methods were applied to test the amount of serum thyroid hormone including T3,T4,RT3,TSH of patients to learn its change rule of liver-Qi stagnation syndrome compared with the control group.64 cases were included in this experiment: 28 cases of liver-Qi stagnation syndrome, 18 cases of non-liver-Qi stagnation syndrome and 18 cases of healthy partakers.ResultsThe preliminary diagnostic standard of liver-Qi stagnation syndrome was generalized as follows:①distension or pain in the chest or flanks；②depression;③dysphoria and irritation;④bitterness in the mouth;⑤compression feeling in the chest;⑥sigh;⑦wiry pulse. One case including<WP=9>four or more than four items of above-noted symptoms and signs can be diagnosed as liver-Qi stagnation syndrome. That the coincidence rate of made standard diagnosis with clinical experts diagnosis was 71% shows that the concordance of made standard with expert diagnosis is pretty well. There isn’t statistical significance in the function state of vegetation nerve in the group of liver-Qi stagnation syndrome compared with the control group (P>0.05). Compared with the control group, total standard marks of SDS and SAS were higher than the common people in China and their increase was statistically significant (p<0.01). The difference of amount of serum thyroid hormone was statistically insignificant in the liver-Qi stagnation syndrome compared with the control group (p>0.05).ConclusionThe self-made diagnostic standard was clinically applicable and can be used for profound clinical investigation in the research of combination of diseases with syndrome. The clinicl investigation scale was simplified as following items: distension or pain in the chest or flanks, depression, dysphoria and irritation, bitterness in the mouth, compression feeling in the chest, sigh, belching, compression and distension in the stomach and belly, distending pain in the lower and side abdomen, symptoms can be induced by nervousness, feeling of foreign body in the throat, red tongue texture. Emotional abnormality which is shown as coexistence of anxiety with depression is one characteristic change in the patients of liver-Qi stagnationsyndrome. What’s more, the main change of emotion of the patients diagnosed as liver-Qi stagnationsyndrome is depression. Comprehensive and compound syndrome and small sample may更多还原