【作者】 刘梅；

【导师】 陈群；

【作者基本信息】 广州中医药大学 ， 中医诊断学， 2008， 博士

【摘要】 舌诊是望诊的一个重要内容,也是中医诊法的特色之一。瘀血舌象在临床很常见,在舌象研究中具有较强的代表性。近十余年来,随着血瘀证研究的重大进展,瘀血舌象的研究已引起广泛关注并取得一定的研究成果,本课题以导师组的前期研究为基础,针对当前舌象研究存在的不足,在基金的资助下,从五脏瘀血舌象形成的共性特征开展研究,系统挖掘五脏瘀血舌象在形成过程中的分布规律、影响因子及与舌象的相关性研究。并结合一些新学科、新技术,开展舌象数字化提取技术和方法学研究,并建立舌象诊断的模糊算法及规则,为实现中医舌象诊断数字化尝试新的方法。论文共包括五个部分:第一部分文献研究本研究包括三部分内容:第一部分:主要系统整理古代瘀血舌象的相关文献。本研究运用手工加计算机检索技术相结合的方法,从瘀血舌象形成的病因、病机、五脏相关性、疾病的关系及治法方药进行系统论述,便于临床应用;第二部分:现代医家从临床观察、实验研究开展瘀血舌象的形成机理研究,大多数学者认为瘀血舌象的形成是在各种致病因子的作用下,由机体相继发生的血流动力学、血液流变学改变以及微循环障碍等综合因素影响的结果。第三部分:随着计算机技术、图像分析技术、人工智能技术等的发展,利用现代科技手段对中医舌象进行客观识别和分析,系统整理舌象信息获取、图像处理技术及舌象仪器的研制等方面进行系统阐述和分析,推动项目组把握研究热点,开展舌象数字化采集和信息获取的技术和方法的研究。第二部分五脏瘀血舌象的临床和实验研究一、五脏瘀血舌象的临床研究研究目的:探讨五脏瘀血舌象的临床表现特征。研究对象:肝、心、脾、肺、肾五脏各100例瘀血舌患者、60例非瘀血舌患者与20例健康人。研究方法:采用前瞻性研究方法,将临床观察与计算机图像自动识别分析相结合。研究结果与结论:1、瘀血舌的舌质研究:瘀血舌组的舌质表现以青紫舌、淡紫舌为主,反应内科疾病的瘀血舌形成多以气血运行失常及气血亏虚导致。2、瘀血舌的舌苔研究:瘀血舌组舌苔多表现为黄厚苔、白厚苔,肾病的舌苔多表现为灰黑苔,说明五脏血瘀的形成病位多在里,与痰湿、气血失衡有关;肾病血瘀证在临床表现程度上讲都较重,因此,多灰黑苔,与久病及肾,肾多虚夹瘀有关。3、瘀血舌的舌下络脉研究:本研究主要从舌下络脉的色泽、宽径、主干长度、主干形态、主干充盈度五个方面探讨瘀血舌的舌下络脉特点。瘀血舌组与非瘀血舌组的舌下络脉色泽按出现频率依次为青紫色＞紫黑色＞紫红色＞淡紫色,宽径均＞4.0mm,主干长度多超过舌下肉阜至舌尖的3/5,主干形态多表现为弥漫性曲张或局限性曲张,主干充盈度以饱满隆起或明显隆起圆柱形多见,外带多见有密网状小血管或囊柱状、粗枝状、囊状突起似葡萄串状。二、临床实验研究研究目的:从分子水平探讨病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,肝、心、脾、肺、肾五脏各100例瘀血舌患者、60例非瘀血舌患者与20例健康人。。研究方法:空腹静脉采血检测以下指标:（1）血清一氧化氮（NO）的测定:硝酸还原酶法;（2）内皮素（ET）、血栓素B₂（TXB₂）、6-酮-前列腺素F_1α(6-Keto-PGF_1α)的测定:RIA法;（3）血液流变学检测。研究结果与结论:1、研究结果1.1五脏瘀血舌象各组的ET、ET/NO均显著高于对照组和非瘀血舌组（P＜0.01）,NO均显著低于对照组和非瘀血舌组（P＜0.01）。1.2五脏瘀血舌象各组的TXB2、TXB2/6-Keto-PGF1α均显著高于对照组和非瘀血舌组（P＜0.05～P＜0.01）,6-Keto-PGF1α均显著低于对照组和非瘀血舌组（P＜0.01）1.3五脏瘀血舌象各组的血沉、血沉方程K值均显著高于对照组（P＜0.01）;此外,瘀血舌组和非瘀血舌组的全血粘度（低切、中切、高切）、全血还原粘度（低切、中切、高切）、红细胞压积、红细胞聚集指数均显著高于对照组（P＜0.05～P＜0.01）;瘀血舌组的全血粘度（低切）、血沉、全血还原粘度（低切、中切）、红细胞聚集指数、红细胞电泳指数均显著高于非瘀血舌组（P＜0.05～P＜0.01）。2、结论2.1 ET—NO失衡是瘀血舌象形成的影响因素之一一氧化氮与内皮素是一对内皮依赖性的血管收缩/舒张因子。瘀血舌患者体内ET-NO平衡被打破,以缩血管因子ET水平升高占优势。瘀血舌患者病变程度较非瘀血舌患者严重。推测ET-NO失衡,尤其ET水平增高是血瘀的病理基础之一,亦是瘀血舌象形成的重要影响因素。认为ET、NO、ET/NO的水平可作为瘀血舌患者诊断、疗效观察和预后分析的参考指标。2.2 TXA₂—PGI₂平衡失调是瘀血舌象形成的关键病理基础TXA2主要是由血小板微粒体合成并释放的一种强烈促进血管收缩和血小板聚集的生物活性物质,而PGI2是由血管内皮细胞合成和释放的一种舒张血管和抗血小板聚集的生物活性物质。生理状态下,TXA2和PGI2作用对立,在血管内皮界面保持一种动态平衡,对调节、维护血小板功能、血管紧张度及心血管内环境平衡稳定起重要的作用。TXA2-PGI2失衡导致舌微循环障碍可能是瘀血舌形成的病理生理学基础。认为综合观察TXB2、6-Keto-PGF1α、TXB2/6-Keto-PGF1α的异常程度可作为判断瘀血舌的客观参考指标。2.3_血液流变学的改变是瘀血舌象形成的最终病理环节瘀血舌象的形成是各种相关理化因子功能失调,最终导致瘀血舌患者血液存在“粘”、“浓”、“凝”、“聚”状态,血液凝聚性增高,最终形成五脏瘀血舌的共同病理基础,导致舌微循环障碍。因此,血液流变学异常引起舌微循环障碍是瘀血舌象形成的最终环节。第三部分舌图像数字化处理技术的研究研究目的:开展图像数字化、标准化研究。研究方法:运用颜色矢量像素法开展舌图像分割,采用模糊数学方法确定舌彩色图像边缘,运用几何数学方法开展舌下络脉数字化研究。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。本研究采用颜色矢量像素法,保留对彩色图像丰富的颜色和纹理等信息进行分割,取得较令人满意的效果,并能确定舌象的边缘,了解舌体大小及反应舌齿痕。运用颜色矢量像素法和几何数学方法提取舌下络脉的长度及宽度,使图像能清晰表现舌下络脉的特征,然后运用数学的方法对其开展数字化研究,推进舌下络脉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。第四部分:舌象特征信息与中医临床数据和病例获取诊断规则的挖掘算法研究研究目的:建立舌象特征信息与中医临床数据之间的诊断规则的算法。研究方法:应用机器学习、数据挖掘、模式识别等方法效果:在综合应用机器学习、数据挖掘、模式识别及中医症状信息量化等方面的研究成果基础上,研究了一种新的FP-growth算法,给出了算法的详细描述,实现了算法的流程,并成功地应用于中医舌诊病例数据库的诊断规则挖掘,测试结果表明该算法速度快,适应性强。模拟中医专家诊断过程的效果令人满意。第五部分结语本课题的创新性:1、以五脏为整体开展瘀血舌象的研究,通过挖掘有效数据,建立五脏瘀血舌象的共性特征,包括临床分布规律及形成机理;2、运用颜色矢量像素法对彩色图像进行分割,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、应用几何数学与颜色矢量像素法开展舌下络脉的图像处理研究,能较清晰获取舌下络脉的信息,便于舌下络脉的数字化诊断研究;4、建立一套适合中医临床诊断的算法规则,便于中医数据的挖掘和应用。更多还原

【Abstract】 The tongue of blood stasis（TBS）is very common in clinic.It is of great clinical significance for the diagnosis and judge of pathological conditions and prognosis of the blood stasis syndrome. It has made great progress on the research of syndrome of blood stasis,relating to the study on the tongue of it.This study took the TBS of five-viscera as the research object,discussed the clinical characteristic and the mechanism of formation of TBS and initially established the characteristic database of TBS of five-viscera by means of many kinds of modernized technologies such as image processing,information fusion,nervous network etc.and 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 supported by the government fund.The thesis is divided into five parts.Part 1 Literature ResearchIt consists of three parts.Firstly,reorganized and studied systematically the literatures which were correlated with TBS of all times and in all countries.Secondly,Doctors in the modern age have studied on TBS from many angles such as clinical observation,experimental study,which occurred one after another in the body under the functions of all kinds of pathogenic factors.The majority of scholars thought the formation of TBS was the result of synthetic factors such as the change of hemodynamics,hemorheology and microcirculation disturbance etc.Thirdly,with the development of computer technology,picture processing and instrument of tongue,the digital research on the diagnosis of the tongue has made great achievement.Part 2 Clinical and Experimental Research on the TBS of Five Viscera.1 Clinical Research on TBS of five visceraObjective:to explore the clinical characteristics of TBSObject:Each 100 cases with liver,heart,spleen,lung and kidney of TBS,60 cases with the with TNBS were observed among patients who were selected on the clinical research,20 healthy cases as control.Method:The prospective study was made.The clinical observation and the automatic recognition and analysis of image by computer were combined.Results and Conclusions:Clinical observation showed that the tongue body of TBS manifested mainly as the pale purplish tongue,bluish and purplish tongue,on the tongue.It indicates that the formation of TBS in the internal disease was the result of abnormal transmission or the deficiency of Qi and blood. The tongue coating often manifested as the yellowish coating and thick and whitish coating, especially gray and black coating is often shown in the nephropathy,and serious abnormality of sublingual vein also existed in patients of TBS.It was thought that the observation of the tongue body had some significance for the diagnosis of TBS and its different pathogenesis of blood stasis; the observation of the tongue coating had important value for the diagnosis of different syndrome types in patients of TBS;And the synthetic observation of the color and luster,diameter,length of stem,shape of stem,filling degree of stem and outer zone of sublingual vein was an important index for the diagnosis of TBS,among which the color and luster of sublingual vein could be the reference to the syndrome differentiation for patients of TBS.2、Clinical Experimental StudyObjective:to explore the pathologic mechanism of TBSC on the molecular levelObject:Each 100 cases with liver,heart,spleen,lung and kidney of TBS,60 cases with the with TNBS were observed among patients who were selected on the clinical research,20 healthy cases as control.Method:hemospasia venous blood on fasting to examine the following indexes:（1）Nitri Oxide（NO）:nitric acid reducing enzyme method;（2）Endothelin（ET）,Thromboxane B₂（TXB₂）,6-Keto-PGF_1α:RIA;（3）Hemorheology examination.Results and Conclusions:1 The balance of the levels of ET and NO was destroyed in the bodies of the patients with the syndrome of blood stasis,which manifested that the levels of ET,ET/NO was significantly higher than those in the control group,the level of NO was significantly lower than that in the control group,and the increase of the ET level was dominant.The degree of pathological changes in patients of TBS was more serious than that in patients of TNBS.It was inferred that the unbalance of the levels of ET and NO,especially the significantly increase of the ET level,was an important factor in the formation of TBS.It was thought that the levels of ET,NO and ET/NO could be used as the reference indexes of the diagnosis,observation of curative effect and analysis of prognosis for patients of TBS.2 The unbalance of the levels of TXA₂ and PGI₂ existed in the bodies of the patients the patients with the syndrome of blood stasis,,which manifested that the levels of TXB₂ and TXB₂/6-Keto-PGF_1αwere significantly higher than those in the control group（P＜0.05～P＜0.01）,the level of 6-Keto-PGF_1αwas significantly lower than that in the control group,and the increase of the TXB₂ level was dominant.The risk of thrombosis in patients of TBS was higher than that in patients of TNBS.It was inferred that the unbalance of the levels of TXA₂ and PGI₂, especially the increase of the TXB₂ level,was the critical pathologic basis in the formation of TBSC.It was thought that the unbalance of the levels of TXA₂ and PGI₂ could reflect the pathologic essence of deficiency accompanied with blood stasis in patients of TBS,and the synthetic observation of the abnormal degree of the levels of TXB₂,6-Keto-PGF_1αand TXB₂/6-Keto-PGF_1αcould be used as an objective index for the diagnosis of TBSC.3 The condition of "viscosity","thickness","coagulation" and "aggregation" existed in blood in patients of TBS,and different syndrome types had the different tendency of "viscosity", "thickness","coagulation" and "aggregation".The increase of the activity of coagulation and aggregation was the common pathologic basis in different blood stasis syndrome types.It was inferred that the formation of TBS is the result of microcirculation disturbance in tongue due to abnormal change of hemorheology to a certain extent.It was thought that the examination of hemorheology could provide the reference to the diagnosis,syndrome differentiation and observation of curative effect for patients of TBSC.4 The formation of TBS was the result of microcirculation disturbance in tongue due to the functional disorder of all kinds of correlated physics and chemical factors.The injury of vascular endothelial cell caused by all kinds of factors was the original factor in the formation of TBS.The unbalance of the levels of ET and NO were the important factors for the formation of TBS.The unbalance of the levels of TXA₂ and PGI₂ was the critical pathologic basis in the formation of TBS.The microcirculation disturbance in tongue due to abnormal change of hemorheology was the last link in the formation of TBS.Part 3 Research on the Picture Processing of the TongueObjective:to explore the digitization,standardization of the diagnosis of the tongue.Method:To divide the image of tongue in the color-vector-pixel way,and to define the edge of the image of tongue with vague mathematics and to study the digitization,standardization on the sublingual vein in geometry.Results and Conclusions:The dividing of image of tongue is premier critical to deal with the image processing by computer.We adopt the color-vector pixel way to maintain the information of color and texture from color image of the tongue.The result is satisfying.We also use it to define the edge and the dental-print of the tongue.Additionally,In the former basis,we study the length and width of sublingual vein in geometry.The result is that it can clearly manifest the character of sublingual vein,and can lay the foundation for the study on the digitization,standardization of it.Part 4 Research on the rule of the Diagnosis of the TongueObjective:to explore the diagnosis rule to data mining the relativity between the character of the tongue and the clinic symptom in the database of the tongue.Method:self-learning of computer,data mining,and pattern recognition.Results and Conclusions:At the beginning,the article analyzed the characteristics of clinical diseases database in the Traditional Chinese Medicine（TCM）tongue intelligent diagnosis processing and the association rules hidden in it.According to these,the program modified the current association rule evaluation system.And then the article gave a detailed description of one new mining algorithms:the modified FP-growth algorithm. It drawn a complete flow chart of the program,and decided to realize the modified FP-growth algorithm using VC++ 6.0 and SQL Server 2000 as the development tools,and applied it to the case database successfully.At last,the article stated the results of tests of the program on clinical diseases database in the TCM tongue intelligent processing and the diagnosis association-rule mining hidden in it.The application result in make clear that,the algorithm this article expatiated can be accurate more and fitter.Part 5 SummaryThe innovation in this study is:（1）This study took TBS of five-viscera as a whole for the first time,explored the clinical characteristic and the mechanism of formation from different levels of entirety,molecule and so on,and provided the objective basis for the diagnosis,treatment,prognosis analysis of TBS（2）To divide the image of tongue in the color-vector-pixel way.It can be maintain the information of color and texture from color image of the tongue and raise the degree of accuracy.（3）To study the digitization,standardization on the sublingual vein in geometry.（4）To Established a suitable arithmetic rule for clinic diagnosis of TCM,and is convenient to data mining and application on the data of TCM.更多还原