【作者】 林铭振；

【导师】 李万瑶；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2011， 博士

【摘要】 三部九候脉诊法,是我国中医自古以来脉诊所使用的一套方法。传统意义上的三部九候诊法把人看作自然界的一个缩影,运用天地人的观点,将人体分为上、中、下三部,每部各分为“天”、“地”、“人”三候,共九部,并认为这九个部分可以反映生活在自然界中人的情况。因通过观察脉象与形体是否相应,上中下三部是否相互调和,以诊察全身病变情况,此种三部九候脉诊法又可称为三部九候遍身诊法,是《内经》惟一列出专篇,用大量笔墨阐述最详尽的脉法(包括切脉部位、主病、辨病、意义等)。与其他脉法比较,突出了定位意义,丰富了《内经》脉学理论,是《内经》脉学理论的精华,为后世脉学发展奠定了理论基础。另一方面,三部九候脉诊法也可用于寸口诊法,《难经》在《内经》寸口脉法的基础上正式确立了“独取寸口诊法”,并赋予了“三部九候”脉诊法新的内容。将寸口脉分寸、关、尺三部,每部各以轻、中、重指力按脉,分浮、中、沉,(《难经·十八难》)故也称为三部九候法。三部九候脉诊法辨病辨证,强调九候相参,综合分析,体现了诊法的整体观思想,其中尤为强调各部各候之间的相互参比意义。因此,研究三部九候脉诊法的溯源、发展、具体运用、临床意义及相关认识等,对中医脉学诊断的理论及实践有非常重要的意义。但当前对三部九候脉诊法源流及应用的文献专门论述相当少,现本研究通过对脉学发展,尤其是对三部九候脉诊理论有重大贡献的《内经》、《难经》、《伤寒论》等典籍著作中的脉学相关内容进行梳理、摘录及分析,从两种不同三部九候脉诊法入手,对其脉学思想、诊脉方法、诊脉技术临床应用、现代客观化研究等几个方面分别进行论述,以期能够基本呈现三部九候脉学的丰富内容。且本研究在文献整理的基础上,结合个人临床经验及平时心得,对三部九候脉诊法提出自已的一些新见解；并据该经典脉诊学说,粗略归纳总结了一套六脉统合图示法,以期为中医脉诊客观化、精确化的研究提供新的思路和方向。目的本研究对当前各种文献、主要中医典籍中的脉学相关内容进行整理、摘录及分析,从三部九候遍诊法及三部九候寸口诊法两部分入手,对该脉诊法的源流、诊脉方法、临床应用、现代客观化研究等几个方面分别进行论述。并结合个人临床实践经验,进行相关客观化研究,以期对疾病的预后、临床辨证施治的指导、以及中医脉诊客观化、精确化的研究提供新的思路和启发,为脉诊研究走向新的高度提供可参考的依据。方法通过文献研究,对三部九候遍诊法与三部九候寸口诊法的的源流、诊脉部位、操作手法、临床应用及现代研究等进行分析、梳理,探讨其形成原因与机理；基于三部九候学说,提出六脉统合图示法,五脏器官脉诊定位法,修正五脏脉位置,提出分寸高骨关尺四部新观念；用拔罐法对受试者进行刺激,观察治疗前后脉象浮中沉、大中小,强弱虚实的变化；观察治疗前后脉率、温度、血压、六脉五脏脉穴位电导值的变化。结果通过对大量文献的分析、整理发现,三部九候遍诊法在《内经》中记载详细且应用广泛,诊脉部位以经络学说为依据,又与针灸取穴有所不同。针灸取穴注重腧穴的定位,即某一腧穴在体表的确切位置,而遍诊法的诊脉部位注重的是经线,并不局限于腧穴的特定位置；就诊脉方法而言,古人经验总结常有切、循、扪、按四种不同而又相互关联的诊法;该诊脉方法能反映脏腑病变,有助于临床分经诊脉、以脉证病、分辨寒热、判断病情轻重、生死及杂病的诊断。现代研究发现,该诊法还可用于诊断循环系统病变、指导针灸施治。且有学者通过采用单点和多部位取脉,运用仿生柔性压力传感器与B超探头复合多路压力传感器,通过对多路信息进行“位、数、形、势”的属性分析,重建动态三维指感脉图,对寸口和三部取脉所得信息进行定量比较研究,证实遍诊法获得的信息量要比独取寸口获得的信息量大。但这种遍身诊法与其它脉诊法相比较,行之于临床有诸多不便,故后世鲜有用之；三部九候寸口诊法源于《内经》、确立于《难经》、完善于《脉经》,其形成原因与机理在各种典籍及现代研究中也有论述阐发；三部九候寸口诊法的部位即为寸口,分寸、关、尺三部,每部各以轻、中、重指力按脉,分浮、中、沉,共九候。关于寸关尺的定位,历代医家有很多论述,对其诊脉部位及分属脏腑历代医家亦有不同认识；其诊脉时间,《内经》中记载以平旦(清晨)时为宜,并提出以呼吸至数来判断脉之快慢的方法；《难经》中提出举按寻的诊脉方法,并一直为后世医家沿用。在此种脉学发展过程中,还总结出了有胃有神有根的平人脉象特征；而病理脉象历代医家各有看法,如《内经》在分散的十二篇中叙述了21种病理脉象,大体划分为七个类型和观察范围,《脉经》首次将病理脉象分为24种,《濒湖脉学》则载病脉27种,同时历代医家也曾用归类法将前人所述脉象“驭简执繁”,及至今人普遍将病理脉分为28种；对于脉诊的客观化,现代学者将现有的各种物理、化学、生物学进展相结合,做过大量相关研究,如脉图、脉波仪、脉象仪的研制,脉象信号的分类识别优化、脉诊专家数据库、中医远程脉诊软硬件的设计等；该种诊脉方法有助于判断疾病的病位病性、指导治疗,对推断疾病的进退预后有很重要的临床价值,临床可应用与内外妇儿各科,运用较为广泛,为后世医家所推崇；拔罐后三部九候脉会有所变化,脉搏数减少,且前后改变率为61.3%；76.1%的受试者寸口部位温度呈寸>关>尺趋势；拔罐后温度拔罐后温度上升者占26.9%;下降者占11.9%；不变者为61.1%；拔罐后,收缩压不变或舒张压不变者占36.3%;收缩压上升或收缩压下降者占37.5%；舒张压上升或舒张压下降者占26.1%；六脉统合数字化与十二经原穴电导变动值之总和及五脏脉电导变动值之总和,无任何相关性。结论与其他脉法比较,三部九候遍诊法在《内经》中记载详细且应用广泛,突出了定位意义,丰富了《内经》脉学理论,是《内经》脉学理论的精华,为后世脉学发展奠定了理论基础；三部九候寸口脉诊法随“独取寸口”理论发展而来,并不断得到完善。该脉法可断五脏六腑及十二经脉的疾病,既宗《黄帝内经》旨义,又有新的创造,临床应用广泛,有助于判断病位病性、指导治疗、预后。其各种形式的客观化研究,是将来脉诊标准化、形象化的重要研究方向。寸口部位拔罐前后温度变化说明,寸部一般温度最高,关次之,而尺脉最低。当三部均一样偏高时,为亢奋、发热；三部均一样偏低时,为低下、失温；单独一部偏高时,则为独热；单独一部偏低时,则为独寒。六脉统合图示法为传统脉学客观化提供了新的思路,值得进一步探讨研究。更多还原

【Abstract】 Three portions & nine pulse-takings is a pulse diagnostic method of Chinese medicine since ancient times. Traditionally, by the theory of three portions & nine pulse-takings, the person was regarded as a microcosm of nature. By using the point of view about sky-earth-human, the human body can be divided into three parts as the upper, the middle and the lower which can reflect the situation of human in nature. By observing whether the pulse corresponds to body and whether the three parts conciliate with each other, the situation of the whole body was observed. This kind of method, called the general pulse diagnostic method of three portions & nine pulse-takings, is the only pulse diagnostic method listed in Neijing. Compared with the other kind of methods, this one emphasized the meaning of location, enriched the pulse theory in Neijing, is the essence of the pulse theory in Neijing, and established the theory foundation for the development of pulse theory.On the other hand, the three portions & nine pulse-takings can also be used for wrist pulse-taking method. Based on Neijing, the wrist pulse-taking method was established in Canon of Difficult Issues and given much more content. The wrist pulse was divided into cun-section, guan-section and chi-section. Each section was divided into the float, the medium and the sunken. It is also known as three portions & nine pulse-takings. This kind of method emphasizes the coherence of the nine symptoms by comprehensive analysis, reflects the holistic mode of thinking, especially the reference meaning between each department and designate.Therefore, the study of the source, the development of specific application, clinical significance and the related awareness about the three portions & nine pulse-takings has very important significance for the Chinese medicine pulse diagnosis theory and practice. However, the current literature about three portions & nine pulse-takings is very little. In this study, the contents about three portions & nine pulse-takings were sort out, extracted and analyzed and discussed from the theory, method, clinical application and modern objective study. Based on these works and combined with some own clinical experiences, some new ideas and a sort of six-meridian incorporative graphical method were brought up for supplement of study on the objectivity and accuracy of Chinese pulse-taking method.ObjectiveIn this study, some materials about pulse in Huangdi’s Internal Classic, Classic of Difficult Issues and Ttreatise on Febrile Diseases were extracted and analyzed from the theory, method, clinical application and modern objective study. Based on these works and combined with some own clinical experiences, some new ideas and a sort of six-meridian incorporative graphical method were brought up for supplement of study on the objectivity and accuracy of Chinese pulse-taking method.MethodsThrough literature study, the source, theory, method, clinical application and modern objective study of the three portions & nine pulse-takings were analuzed and discussed.Based on the theory of three portions & nine pulse-takings, a sort of six-meridian incorporative graphical method, zang-fu pulse-locating method were brought up, and some new idea about the four Categorization of wrist pulse.Cupping method was used to stimulate the subjects to observe the changes of pulse manifestation, pulse rate, temperature, and blood-pressure, electric conductivity before and after treatment.ResultsThrough literature study, the general pulse diagnostic method is recorded in detail and used widely. The location of pulse-taking is based on the theory of meridians and collaterals, but also different with it. Acupuncture focus on the exact position of acupoints on the body surface, while for the general pulse diagnostic method, it is meridian; as far as the method of diagnose is concerned, there were four different but interrelated diagnostic method, such as taking, searching, palpation and pressing which can reflect the disease of the internal organs, be helpful to diagnose the troubles by pulse syndrome, to distinguish heat and cold, to determine the severity, life and death, and miscellaneous disease diagnosis. Modern research has found that the diagnostic method can be used for diagnosis of circulatory system diseases, guidance acupuncture treatment. And some scholars studied the information from wrist pulse to confirm the information acquired from the whole body is much more than that from the wrist by using bionic flexible pressure sensor and B-probe complex multi-pressure sensors. But compared with the other methods, this general pulse diagnostic method is not so convenient in clinic, so it is rarely used later;The three portions& nine pulse-takings in wrist is sourced from Neijing, established in Classic of Difficult Issues and finished in Pulse Classic. The formation and mechanism were discussed in different materials. The taking position is wrist and can be divided into the cun, the guan, the chi. each section was divided into the float, the medium and the sunken. About the location of the cun, the guan and chi as well as the zang-fu position there are many different descriptions. In Nei jing, the right time for taking pulse is morning; In Classic of Difficult Issues, the pulse-taking methods are lifting, pressing and searching. The normal pulse manifestation has stomach, vitality and root; for the abnormal pulse manifestation, different clinical practitioners have different opinions. For the objectivity of pulse diagnosis, modern scholars had done much effort to study.After cupping, the three portions & nine pulse-takings were changed, the pulse rates reduced and the changing rate was 61.3%; in 76.1% of the subjects, it was shown that the temperature of the cun was highest and that of the chi was the lowest; after cupping, the temperature of 26.9% of the subjects raised; the temperature of 11.9% of the subjects reduced; the temperature of 61.1% of the subjects didn’t change; after cupping, the rate of systolic blood pressure or diastolic blood pressure remained unchanging in the same account was 36.3%; 37.5% of the subjects was with systolic blood pressure increased or systolic blood pressure decreased; 26.1% of the subjects with diastolic blood pressure increased and diastolic blood pressure decreased; six digital pulse integration points with the second by the original value of the sum of the changes in conductivity and conductance changes in the value of the five internal organs of the sum of the pulse. There was no any relevance.ConclusionCompared with the other methods, the three portions & nine pulse-takings emphasized the meaning of location, enriched the pulse theory in Neijing, is the essence of the pulse theory in Neijing, and established the theory foundation for the development of pulse theory.The three portions & nine pulse-takings in wrist were developed from the theory of wrist-pulse diagnostic method and finished gradually. This kind of method is not only based on the essence of Neijing, but also has new creation. It is widely used in clinic and helpful for distinguish the position and nature of diseases, guidance of treatment and prognosis. The objective studies of it are the important researching aspect for the standardizing and visualization of pulse diagnosis.Changing of temperature before and after cupping shows that the temperature of the cun was highest and that of the chi was the lowest. When the temperature of the three parts is high which indicates excess and fever; while on the contrary, which indicates insufficiency and cold; when that of single one section is high, which indicates the one-hot; on the contrary, which indicates independent cold.Six-pulse integration graphic method provides a new train of thought for the objective study of traditional pulse and is worthy of further investigation research.更多还原