【作者】 张瑞江；

【导师】 陈群；

【作者基本信息】 广州中医药大学 ， 中医诊断学， 2010， 博士

【摘要】 血瘀证是中医临床中最常见的病证之一,是心脑血管疾病等多种复杂性重大疾病的共同证候。研究血瘀证是我国防治复杂性重大疾病的重大需求。另一方面,在中医学的各种辨证体系中,血瘀证属于气血津液辨证的血证,属于脏腑辨证的心、脑、肝等重要脏腑的共有证,故血瘀证也是中医诊断和治疗疾病的重大基础,在血瘀证方面进行规范化、标准化、数量化、模型化的研究,对整个中医证候规范化研究都具有重要的现实和理论意义。所以本研究在中医传统理论指导下,继承中医传统思维,遵循循证医学理念,梳理有关血瘀证的文献,整理前人的思路,继承并发扬古代文献的精华,结合当代专家经验体会及对血瘀证症状、体征的特色认识,发挥专家的群体作用,来编制科学合理的血瘀证证候及相关因素调查问卷。在此基础上,通过信息熵,利用模糊数学方法建立起血瘀证传统辨证诊断模糊集以及利用数学分形理论提取血瘀证各亚型的主要症状、体征,从而使血瘀证诊断更明确,处方用药更细腻熨帖,并探讨建立中医证候诊断数学模型的思路和方法。研究得到如下结果：1、首先对有关血瘀证的古代及现代文献进行整理,统计出血瘀证的主要症状、体征。在此基础上,通过专家问卷调查法对广州中医药大学第一附属医院副高以上职称的临床中医师进行血瘀证入选项目的筛选调查,从临床医生的角度来探讨血瘀证的宏观辨证诊断。故本课题组在整理古代及现代有关血瘀证症状、体征的基础上,结合预实验结果,制定了血瘀证传统宏观诊断入选项目专家咨询问卷,以问卷调查形式开展血瘀证传统宏观诊断入选项目专家咨询工作。专家意见表明,舌质紫暗、固定性疼痛、病理性肿块、舌体瘀斑、舌脉曲张等症状、体征是临床血瘀证宏观诊断的主要依据。另外,在咨询过程中专家特别强调血瘀证的研究要结合病种进行,若仅凭舌质紫暗等共同表现用药,临床疗效不够好。专家问卷调查对于血瘀证传统宏观诊断入选项目的确定及后期研究具有重要的参考意义,我们将综合专家意见和文献研究来制定血瘀证宏观诊断调查表及后期研究。2、结合文献研究、专家调查和预实验的结果,制定了具有较大涵盖面的血瘀证宏观辨证诊断临床流行病学调查表,严格按照DME和医学群体调查设计的要求,对心血管内科、神经内科、消化内科、肾内科、呼吸内科、外科、妇科、儿科、血液科、肿瘤科等各科的血瘀证患者进行了大样本的临床流行病学调查,按照模糊数学的思想方法,参照1988年在北京血瘀证研究国际会议上制定的血瘀证诊断标准,结合临床实际,分别建立了男性和女性血瘀证宏观诊断的模糊集。将该模糊集与1986年第二届全国活血化瘀研究学术会议制定的血瘀证诊断标准相比较,诊断结果相当一致,说明其具有一定的可靠性,值得进一步验证和研究。同时,血瘀证宏观诊断模糊集的创建也为中医证候的量化研究提供了新的思路和方法。3、我们利用信息熵,按照分形的思想和方法,对来自广州中医药大学第一附属医院病房的407例血瘀证各亚型患者临床诊断数据进行了分析,包括气虚血瘀证、气滞血瘀证、寒凝血瘀证、热结血瘀证、痰阻血瘀证、阴虚血瘀证、阳虚血瘀证、血虚血瘀证八种亚型。利用血瘀证症状、体征对各亚型的信息贡献率,提取血瘀证各亚型的主要症状、体征。气虚血瘀证的主要症状、体征,根据信息贡献率由大到小分别为气短乏力、固定疼痛、舌质淡暗、舌脉曲张、脉涩。气滞血瘀证的主要症状、体征,根据信息贡献率由大到小分别为舌质紫暗、胁肋胀痛、脉弦、胸闷、抑郁。寒凝血瘀证的主要症状、体征,根据信息贡献率由大到小分别为口唇青紫、手足不温、局部固定痛、得温痛减、脉沉紧。热结血瘀证的主要症状、体征,根据信息贡献率由大到小分别为舌绛紫、高热、口燥咽干、固定疼痛、衄血。痰阻血瘀证的主要症状、体征,根据信息贡献率由大到小分别为舌质紫暗、舌体瘀斑、咯痰、胸闷、固定疼痛。阴虚血瘀证的主要症状、体征,根据信息贡献率由大到小分别为五心烦热、舌紫暗、消瘦、固定疼痛、口燥咽干。阳虚血瘀证的主要症状、体征,根据信息贡献率由大到小分别为形寒肢冷、面色黧黑、固定疼痛、气短乏力、脉沉迟、心悸。血虚血瘀证的主要症状、体征,根据信息贡献率由大到小分别为面白无华或萎黄、舌质紫暗、头晕眼花、脉细涩、肢体麻木。本研究在传统中医理论的指导下,依照循证医学理念,运用临床流行病学的原理和方法,通过对古典及现代文献的调研和临床流行病学调查,收集临床病例。在此基础上以信息熵为载体,运用模糊数学和数学分形的思想方法初步建立血瘀证传统辨证诊断的模糊集和提取各血瘀证亚型的主要症状、体征。在中医药研究中引入数学方法、建立数学模型,运用数学结构和数学语言表达中医学的理论内容,有助于中医学逐步走上数量化、标准化、规范化和现代化的发展轨道。更多还原

【Abstract】 Blood stasis syndrome, which is one of the most common diseases in the Chinese clinic, is the common syndrom of cardiovascular, cerebrovascular and many other complicated and serious diseases. Research on blood stasis is the major demand of prevention and treatment of the complicated and serious diseases in our country. On the other hand, in every syndrome differentiation system of traditional Chinese, blood stasis syndrome belongs to blood syndrome, the differentiation of qi, blood and fluid and it belongs to the common syndrome of the important organs like heart, brain, liver,the zangfu-organs differentiation, so blood stasis syndrome is the great foudation of Chinese medical diagnosis and treating diseases. Research on the standardization, quantification and modeling of blood stasis syndrome has great practical and theoretical significance in the whole standardization research of Chinese medicine syndrome.Therefore, under the guidance of traditional Chinese medicine theory, inheriting traditional Chinese thinking, following the evidence-based medicine concept, collating literature related to blood stasis and the previous ideas, inheriting and carrying forward the essence of ancient literature and combining with the experence and characteristics knowledge of the symptoms and signs of blood stasis syndrome by the modern experts, this study plays the role of expert groups to prepare a scientific and reasonable questionnaire about blood stasis syndrome and the related factors. On this basis, through the information entropy, traditional differentiation diagnosis fuzzy sets are established by fuzzy mathematics method and the main symptoms and signs of blood syndrome subtypes are selected by the use of fractal mathematics, making the blood stasis syndrome diagnosis more clear and the prescriptions more precise. And this study explores the establishment ideas and methods of mathematical models of Chinese medicine syndrome diagnosis. The research results are as follows:First, collating the ancient and modern literature about blood stasis syndrome and counting the main symptoms and signs of blood stasis syndrome. On this basis, through a questionnaire survey of experts, the clinical associate professors or above in the first affiliated hospita of Guangzhou university of traditional Chinese medicine for screening survey of blood stasis syndrome selected items, it explores the macro-differentiation diagnosis of blood stasis syndrome from the viewpoints of clinicians. Therefore, based on the related symptoms and signs of ancient and modern literature and the combination of pre-test results, the research group has developed selected items of macro traditional diagnosis of blood stasis syndrome for the experts consultation questionnaire and carried out this work by the form of questionnaire survey. The experts’opinions show that the symptoms and signs like the dark purple tongue, fixed pain, pathologic tumor, petechiae tongue and varicose veins under the tongue are the main bases for macroscopic diagnosis of blood stasis syndrome clinically. In addition, during the consultation process, experts placed particular emphasis that the research should be combined with blood stasis diseases and the clinical efficacy will not be good enough if using drugs only according to the common performance like dark purple tongue. The experts questionnaire survey has great referential significance for the goal determination of selected items of macro traditional diagnosis of blood stasis syndrome and the post research. We will make out the macro diagnosis questionnaire form and do the post research according to the advice of expers and the literature.Second, combining with the literature research, experts questionnaire survey and the pre-test results, a clinical epidemiology survey form has been made for the greater coverage of macro-differentiation diagnosis of blood stasis syndrome. Strictly in accordance with DME and the survey design requiremennts for medical groups, a large sample of clinical epidemiology survey has been made for the blood stasis syndrome patients from every department like cardiology, neurology, gastroenterology, nephrology, pneumology, surgery, gynecology, pediatrics, hematology and oncology. According to the fuzzy mathematics method and the blood stasis syndrome diagnostic criteria made in the Beijing International Conference on blood stasis syndrome research in 1988 and combining with the clinical practice, the blood stasis fuzzy sets in macro diagnosis for men and women have been established separately. Compared with the blood stasis diagnostic criteria made in the Second National Academic Conference on activating blood and dissolving stasis research in 1986, the diagnostic results of these sets are quite similar, indicating that the sets have certain reliability, worthy of further verification and research. And the estabilshment of macro diagnostic fuzzy sets of blood stasis syndrome provides new ideas and methods for quantitative study of Chinese medicine syndromes.Third, using information entropy and according to the fractal ideas and methods, the clinical diagnosis data has been analyzed about 407 cases of blood stasis, every subtypes in-patients from the first affiliated hospital of Guangzhou university of traditional Chinese medicine, including blood stasis due to qi deficiency, qi stagnation, cold coagulation, heat stagnation, phlegm obstruction, ying deficiency, yang deficiency and blood deficieny syndrome, eight subtypes. The main symptoms and signs of every subtype of blood stasis syndrome are selected by the information contribution rate of those to every subtype. Accordiong to the information contribution rate, from big to small, the main symptoms and signs of blood stasis due to qi deficiency syndrome are shortness of breath, fatigue, fixed pain, dark pale tongue, varicose veins under the tongue and astringent pulse; the main symptoms and signs of blood stasis due to qi stagnation syndrome are dark purple tongue, hypochondrium distending pain, string pulse, chest tightness and depression; the main symptoms and signs of blood stasis due to cold coagulation syndrome are purple lips, cold hands and feet, local fixed pain,pain reduced by warmness and deep tight pulse; the main symptoms and signs of blood stasis due to heat stagnation syndrome are crimson and purple tongue, high fever, dry mouth and throat, fixed pain and bleeding; the main symptoms and signs of blood stasis due to phlegm obstruction syndrome are dark purple tongue, petechiae tongue, cough with sputum, chest tightness and fixed pain; the main symptoms and signs of blood stasis due to ying deficiency syndrome are dysphoria with feverish sensation in the chest, palms and soles, dark purple tongue, emaciation, fixed pain and dry mouth and throat; the main symptoms and signs of blood stasis due to yang deficiency syndrome are intolerance of cold, cold limbs, black complexion, fixed pain, shortness of breath, fatigue, deep and slow pulse and palpitation; the main symptoms and signs of blood stasis due to blood deficiency syndrome are pale,dim or sallow complexion, dark purple tongue, dizziness and blurred vision, thready and astringent pulse and numbness of limbs.This study is under the guidance of traditional Chinese medicine theory, following the evidence-based medicine concept, applying the principles and methods of clinical epidemiology, through making classical and modern literature research and clinical epidemiology survey and collecting clinical cases. On this basis, using the information entropy as the carrier and the thinking method of fuzzy mathematics and fractal mathematics, the traditional differentiation diagnosis fuzzy sets are established initially and the main symptoms and signs of every subtype of blood stasis are selected. In the Chinese medical research, the intrduction of mathematical methods, the establishment of mathematical models, the using of mathematical strcutures and the expression of mathematical language for the theory of Chinese medicine help to make Chinese medicine gradually develop into the track of quantification, standardization and modernization.更多还原