【作者】 王静；

【导师】 莫传伟；

【作者基本信息】 广州中医药大学 ， 中医诊断学， 2009， 硕士

【摘要】 目的本研究在邓铁涛教授的五脏相关理论的指导下,分别对慢性阻塞性肺疾病急性加重期和慢性心力衰竭两种疾病的中医临床证候进行深入研究,尝试通过临床流行病学和非线性主成分分析、结构方程模型等多元统计方法探讨中医五脏相关的数量关系。方法本研究采用横断面调查方法收集数据。由973课题《中医五脏相关理论继承与创新研究》临床研究组按照方案要求,收集广东省中医院住院和门诊慢性阻塞性肺疾病急性加重期患者266例、慢性心力衰竭患者373例,完成中医临床证候流行病学调查表。用EpiData软件建立数据库,用StatTrans软件对数据库类型进行转换,建立SPSS、SAS统计软件支持的规范数据库。运用SAS9.1软件,分别对两个数据库五脏各自症状进行非线性主成分分析,各提取五个主成分,代表五脏各自症状的综合指标。并用五脏的综合指标,采用结构方程模型等多元统计方法分别研究两种疾病的五脏相互之间的定量关系。运用SPSS15.0软件做相关与回归分析,用Spearman相关分析与逐步多重线性回归研究一脏与其它四脏症状间的关系。用AMOS7.0软件绘制通径图。结果在慢性阻塞性肺疾病急性加重期临床研究中,收集了有效病例266例。这些病例中医辨证主要是肺胀,约占95.5%。描述性统计结果表明,肺、肝、脾、肾、心五脏有效症状分别有42个、11个、28个、22个、16个。采用非线性主成分分析方法,提取5个主成分,每个主成分代表其原始数据90%以上的信息,记作“肺”、“肝”、“脾”、“肾”、“心”。采用结构方程模型分析,结果提示:脾-肺、肺-肾、脾-肾、心-脾、心-肺之间呈现正相关,心-肾之间呈现负相关。其中,肺脾肾心四脏密切相关,涉及两脏相关最为密切的是肺肾,其次是心肺、脾肺、心脾、脾肾;涉及三脏相关较为密切的是心肺肾、脾肺肾,其次是心脾肺;涉及四脏相关较强的有心脾肺肾。从总体效应来看,脾-肺、肝-肾、肝-肺、肝-脾、脾-肾之间呈现正相关。与五行学说相符的关系有脾土生肺金、心火生脾土、肺金生肾水、肾水克心火。选取数据收集较为完整的“肺”、“脾”、“肾”,采用相关与回归分析其与其它四脏症状之间的关系,结果提示:肺脏与脾肾心三脏的症状关系密切,病机主要反映在脾失健运,肾气虚弱,心血虚等方面;脾与肺肾心肝相关,病机主要反映在肺肾水液代谢障碍、心血虚、肝气郁等方面;肾与肺肝脾心相关,病机主要反映在脏腑阴阳失调方面。在慢性心力衰竭的临床研究中,收集了有效病例373例。描述性统计结果表明,肺、肝、脾、肾、心五脏有效症状分别有34个、23个、42个、25个、15个。采用非线性主成分分析方法,提取5个主成分,每个主成分代表其原始数据95%以上的信息,记作“肺”、“肝”、“脾”、“肾”、“心”。采用结构方程模型分析,结果提示:脾-肺、心-脾、肾-肝、肝-脾之间呈现正相关,脾-肾之间呈现负相关。脏与脏的间接效应较弱。从总体效应来看,肝对脾具有正向效应。与五行学说相符的关系有脾土生肺金,心火生脾土,肾水生肝木,脾土克肾水。采用相关与回归分析一脏与其它四脏症状之间的关系,结果提示:心与肺脾肾相关,病机主要反映在心肺气虚,脾失健运,水液停聚,痰瘀久而化热等方面;肺与心脾肝肾相关,病机主要反映在痰瘀扰心,神志异常,肺脾气虚,肝阴血虚,肾阳虚等方面;脾与肺心肝肾相关,病机主要反映在心脾血虚,痰浊阻肺,肝阴血虚、虚火内扰,脾肾阳虚等方面;肾与肺脾肝相关,病机主要反映在肺肾气虚外感,脾气虚,肝肾阴虚等方面;肝与肺脾肾心相关,病机主要反映在痰浊阻肺,心肝血虚,神志异常,脾虚水泛,肾精血虚等方面。结论结构方程模型是一种强而有力的分析工具,本课题运用结构方程模型和非线性主成分等多元统计方法研究中医五脏相关理论,在方法学上具有重要的实证意义。本研究采用非线性主成份分析、结构方程模型、相关与回归的方法对两组中医临床数据进行综合分析,对慢性阻塞性肺疾病急性加重期的研究,结果提示:肺脏与脾肾心三脏相关,尤以心肺肾、脾肺肾这两种模式相关关系较为密切,与中医理论是相符合的。同时还得出脾-肾、脾-心、肺-肝、肝-肾正相关,心-肾负相关,验证了五行学说中“土生金”、“火生土”、“水生木”、“水克火”的经典理论。对慢性心力衰竭的研究,研究结果提示:心与脾相关较为密切,同时还得出脾-肺、肾-肝、肝-脾正相关,脾-肾负相关。验证了五行学说中“火生土”、“土生金”、“水生木”、“土克水”的经典理论。不同疾病,不同发展阶段,证候表现同样反映多脏腑相关的特点。病情越重,涉及病变的脏腑越多,证候组合越复杂。本研究中两部分临床数据表明,五脏的任意两脏之间都是相互影响、相互促进的,一脏功能异常,都会影响到其它四脏。从一种或多种重大疾病的临床研究出发,系统探索五脏相关的理论内涵,以指导临床诊治现代疑难病症,具有重要的现实意义。更多还原

【Abstract】 ObjectiveThis thesis is to explore quantitative relationship of five viscera, according to the researches on studying CM (Chinese medicine) symptoms of acute exacerbations of Chronic Obstruct Pulmonary Disease (COPD) and Chronic Heart Failure respectively by the methods of clinical epidemiology and non-linear principal component analysis, structural equation model, etc.MethodsThe data collecting was acuired from cross-sectional survey. In accordance with the program’s requirements, the clinical research team of 973 Project, Inheritance and innovation Research of the doctrine of the correlation of five viscera, used clinical epidemiological methods to collect the research cases from inpatients and outpatients in Guangdong Provincial Hospital of Chinese Medicine and then completed epidemiological questionnaire of clinical syndroms of CM. The cases included 266 cases of the acute exacerbations of COPD and 373 cases of that of Chronic Heart Failure respectively. Using softwares of Epidata and StatTrans to establish two regular databases of five visceral symptoms about two diseases, all the data were analyzed by SPSS15.0, SAS9.1 and AMOS7. 0 on the relevant statistic models. Non-linear principal component analysis was used to extract 5 principal components respectively, on the two databases with SAS9. 1, which represented aggregative indicators of respective viscera CM symptoms. Based on the 5 principal components, structure equation modeling was used with SAS9.1 to explore their quantitative relationship of five viscera. By means of SPSS15. 0, spearman correlation analysis and stepwise multiple linear regression were used to study relations between each aggregative indicator and other four viscera CM symptoms. Path graphs were made by AMOS7.0. ResultsDuring the clinical research of the acute exacerbations of COPD , there were 266 effective cases collected. Most cases(95.5%) were diagnosed Lung Distension through differentiation of syndromes in CM. Descriptive analysis shows that the quantity of effective CM symptoms set in advance in lung was 42, in liver was 11, in spleen was 28, in kidney was 22, and in heart was 16. From the results of final non-linear principal component analysis, each component could explain more than 90% information of raw data, named as Fei, Gan, Pi, Shen and Xin. Structural equation modeling analysis suggests that a positive correlation could be showed between spleen and lung, lung and kidney, spleen and kidney, heart and spleen, and heart and lung, however, a negative correlation between heart and kidney. On the other hand, lung, spleen, kidney and heart contacted closely with each other. Involving two viscera, it is closely related beween lung and kidney, next heart and lung, spleen and lung, heart and spleen and spleen and kidney. Involving three viscera, it is closely between heart and lung and kidney, next between spleen and lung and kidney, next is the heart and spleen and lung. Involving four viscera, it is closely related between heart and spleen and lung and kidney. Judging from the total effect, a positive correlation can be showed between spleen and lung, liver and kidney, liver and lung, liver and spleen, spleen and kidney. These results were in line with part of the theory of Five Elements Theory, such as earth (spleen) generates metal (lung), fire (heart) generates earth (spleen), metal (lung) generates water (kidney) and water (kidney) restricts fire (heart). Selecting data from Fei, pi and shen which were more complete relatively and carrying on correlation and regression method to analyze the relationship between their principle components and the other four viscera symptoms, the results suggested that lung was closely related with spleen, kidney and heart symptoms, the pathogenesis mainly reflected malfunctions of spleen, deficiency of kidney qi, deficiency of heart blood. Spleen was closely related with lung, kidney, heart and liver symptoms, the pathogenesis mainly reflected disturbance of water metabolism, deficiency of heart blood and stagnancy of liver qi. Kidney was closely related with other four viscera symptoms, the pathogenesis mainly reflected dysfunction of the viscera and imbalance between yin and yang.During the research of Chronic heart failure ,373 effective cases were collected. Descriptive statistics analysis showed that the quantity of effective CM symptoms set in advance in lung was 34, in liver was 23, in spleen was 42, in kidney was 25 and in heart was 15. From the results of final non-linear principal component analysis, each component could explain more than 95% information of raw data, named as Fei, Gan, Pi, Shen and Xin. Structural equation modeling analysis suggested that a positive correlation could be showed beween spleen and lung, heart and spleen, kindey and liver and liver and spleen, however, a negative correlation beween spleen and kindey. However, the indirect effect among five viscera was weak. Judging from the total effect, Liver had a positive effect on the spleen. These results were in line with part of the theory of Five Elements Theory, such as earth (spleen) generates metal (lung), fire (heart) generates earth (spleen), water (kindey) generates wood (liver), earth (spleen) restricts water (kindey). Correlation and regression analysis showed that the heart was closely related to lung, spleen and kindey symptoms, the pathogenesis mainly reflected deficiency of lung and heart, malfunctions of spleen, internal retention of water and disorder by phlegm and heat. The lung was related to spleen, liver, kindey and heart symptoms, the pathogenesis mainly reflected obstruction of heart by phlegm stagnancy, abnormal consciousness, deficiency of qi of both lung and spleen, deficiency of liver yin and blood and deficiency of kidney yang. The spleen was related to all other four viscera symptoms, the pathogenesis mainly reflected deficiency of blood of both heart and spleen, obstruction of lung by phlegm, deficiency of liver yin and blood, disorder by phlegm and heat and deficiency of yang of both spleen and kidney. The kindey was related to lung spleen and liver symptoms, the pathogenesis mainly reflected deficiency of qi of both lung and kidney, deficiency of spleen qi and deficiency of yin of both liver and kidney. The liver was related to all other four viscera symptoms, the pathogenesis mainly reflected obstruction of lung by phlegm, deficiency of blood of both heart and liver, abnormal consciousness, edema due to spleen yang deficiency and deficiency of kidney-essence.ConclusionStructural equation modeling is a powerful analytical method. Using the structural equation modeling and non-linear principal component analysis, it is of methodological significance to explore the doctrine of the correlation of five viscera. This thesis comprehensively analyzes CM symptoms of two diseases respectively, acute exacerbations of COPD and Chronic Heart Failure. The conclusion of the former suggests that the lung is revelent to spleen, kindey and heart, especially the two modes of three viscera of intercorrelation are heart and lung and kidney, spleen and lung and kidney. Those are in line with the theory of Chinese medicine. Meanwhile, positive correlation is showed between spleen and kindey, spleen and heart, lung and liver and liver and kindey, however, negative correlation is showed between heart and kindey. The results can up to part of the theories of the Five Elements Theory, such as earth generates metal, fire generates earth, water generates wood and water restricts fire. The conclusion of the latter suggests that the heart is revelent to spleen, meanwhile, positive correlation is showed between spleen and lung, kindey and liver, liver and spleen, negative correlation is showed between spleen and kindey. The results can can up to part of the theories of the Five Elements Theory, such as fire generates earth, earth generates metal, water generates wood and wood restricts water. Different diseases, different stages of diseases, the syndrome reflects the characteristics of multi-organ-related. The more serious condition, the more organs involve, the more complex combination syndrom.Come to a general conclusion, any two viscera are mutual effected and promoted each other. The dysfunction of one viscera can affect the other fours. From clinical researches of one or more major diseases, it is very important and practical and significant to systematically explore the connotation of of the correlation of five viscera in order to guide clinical diagnosis and treatment of modern complicated illnesses.更多还原