【作者】 王中杰；

【导师】 王洪琦；

【作者基本信息】 广州中医药大学 ， 中医基础理论， 2012， 博士

【摘要】 目的：有关中医思维方式的研究多年来成果虽多,但研究的结论比较支离破碎,以致于面对以西医思维对中医理论作出的错误理解和批评的时候,感到回应乏力,甚至妄自菲薄而涌现大量以现代科学理论与方法所进行的各种中医药研究。为了解决这个有关中医专业何去何从的迫切性问题,本研究课题试图为中医思维方式的本质进行诠释。方法：中医思维方式研究的方法从历史的角度看待中医思维方式的发生发展,中医思维方式就是一种历史传承物。其载体包括临床实践、医案和医学理论。基于中医思维方式是一种历史传承物,对其进行研究已超出了自然科学的研究范围。因此,借助了哲学诠释学的原理来建构一个中医思维方式的研究框架,并就其诠释自觉地筹划了属于三个层面的六种与效果历史的对话：一、《内经》思维形成的背景；二、《内经》思维的运用；三、《内经》思维的发展；四、《内经》思维的当代冲击(前四者属理论层面)；五、医案(属医案层面)；六、临床应用(属临床层面)。鉴于研究范畴之大,本课题只会于理论层面对中医思维方式进行诠释,尝试总结出一种具学术和传承意义的阶段性研究结果。本课题诠释开始前的前把握根据哲学诠释学,任何诠释开始于前把握,即基于先前拥有(即前有)的知识于诠释开始前已对诠释对象产生的可能性诠释。按思维的基本形式而言,思维方式有概念思维和意象思维。概念思维是包含了感官知觉、概念形成、信念定立、知识获得四个阶段,以概念为思维的基本形式,建构起来的知识体系指代着现成的、静态的、确定的事物。意象思维则是包含了“观”、“取”、“立”、“见”、“通”五个阶段,以意象为思维的基本形式,建构起来的知识体系指代着生成的、动态的、可能的事物。基于前有的知识,初步认为载于《内经》的中医知识体系,是以生成的、动态的、可能的意象所建构的,故将本课题诠释开始前的前把握定为意象思维。《内经》思维形成的背景沿着古代中国到两汉这一时间主轴,探讨了相关的历史、文化思想、思维等发展,认识到天人关系和伴随其发展的意象思维这一庞大结构,涵盖了几乎所有中国古代的思想及实用知识,医学难有例外。成篇于战国初期至西汉时期的《内经》,观其天道与人道的观念,气、阴阳与五行的运用,人的内部和人与社会、自然之间和谐协调的提倡,必然受天人关系发展的影响,故其理论必然以意象思维而建构。《内经》思维的运用古代中国的医家从事物变化运动的角度对人体现象进行观察。在人体内,某些有形实体和无形实体的运动组合所展现的,可以是彰显功能的变化运动状态,如脏腑；可以是彰显信息传递的变化运动状态,如经络：可以是彰显性态的变化运动状态,如气血津液。它们通过“立”以藏象的形式给出,再通过“见”,以气、阴阳与五行归类、划分层次和连系,形成藏象学说、气血津液学说和经络学说。通过“观”、“取”,可以获悉有规律的气血运动综合表现出的动态之势,再通过“立”以藏象给出,即健康状态、病机或证。动态之势在境域内是常规,围绕着动态之势起干扰作用的运动,是变数。平人状态的气血运动规律正常,综合表现出的是正气内守之常或生长壮老已之常；起干扰作用但未致使质变的,表现为体质差异之变。干扰作用一旦引致质变,气血运动规律由正常变为异常,表现为疾病。病患者综合表现出的动态之势就是病机或证(常)；起干扰作用但未致使质变的,表现为兼证(变)。干扰作用一旦引致质变,气血运动规律或由异常变为正常,表现为疾病的治愈；或由现有异常叠加了另外一种异常,表现为疾病的并发；或由异常变为停止,表现为死亡。正常状态的运气表现为有序的四时变化,并无干扰人体气血运动,不易使人发病；异常状态的运气表现为无序的四时变化,干扰人体气血运动,易致发病。就治疗而言,就是为病机或证所表现的异常规律的动态之势或正势,拟定一种反势,正反势相合而抵消,致使阴阳平衡,转化为平人体内起主导作用的常势。这也就是“通”的贯彻。整套以意象思维建构的医学理论,最终通过“见”以《内经》的文字展现。当中理论所蕴含的,正是人体气血运动规律的阐释,以及如何运用意象思维去处理人体气血运动规律所处境域中出现的常变问题。《内经》思维的发展医学作为中国传统文化的一部分,当然受其洪流所影响。无论是黄老道学、传统儒学或理学的宇宙图式,都是以天人关系及其伴随的意象思维这一庞大结构所建构的,所蕴涵的就是一种生成的、动态的、可能的认知体系。正是这种认知体系所构成的宇宙图式,被医学所借用,并建立起以五脏运动为中心呈辐射式向宇宙万物开放的时空构架。医学意象思维模型最初以心理语言形成于医者的意识中,为现场临床诊治所用；之后又以自然语言出现于文本理论中,为交流和传承所需。医学意象思维模型,就是在现场与离场之间反复琢磨中传承下来,成为一种历史传承物,被医家从临床反馈中不断地诠释,形成了理论-实践的循环。医学意象思维模型作为历史传承物,到两宋时期已发展成以藏象-诊治体系为主、藏象-养生体系为副、运气体系为参、气味体系为援的庞大结构。在藏象-诊治体系的发展中,又有偏重于藏象一端的经典研究,又有偏重于诊治一端的医方书涌现,也有两者兼备的综合性医方著作,以及就事情本身需要而衍生出的临床各种专科,但藏象一诊治体系总的依然主导着医学意象思维模型的发展大势。金元时期以降,医学主张、医家学说甚至医家学派陆续出现,正揭示了该思维模型发展已积累到相当的程度,使医家的处方用药每蕴涵了自身的诊治思路。如果中医学术思想的发展,在两宋时期或以前为敛聚、自为,以建立并丰富医学意象思维模型中各种体系为要旨；那么,由金元时期至清末为绽放、飞跃,以医者发扬医学意象思维模型中的内蕴为特征。由清末到现在,该思维模型的发展出现了挑战,一种截然不同的医学思维模式,正试图改变中医固有的思维模式。成果：对于中医思维方式的诠释,最终得出本课题研究的结果：中医的思维方式为意象思维,其本质是一个以双回路诠释学循环为基本单位的诠释学循环网络,其体现是整个中医专业的临床实践和医学传承；而临床实践是医者此在本身的存在方式；临床实践的总和与医学传承一起,是整个中医专业的存在方式。最后,带着这些最新的前理解,去面对今天西方医学为意象思维带来的冲击。《内经》思维的当代冲击就今天现代医学的冲击,从历史的角度探讨了西医思维方式的生成与发展后,得出关于西医思维方式本质的诠释：西医的思维方式为概念思维,其本质是一个以两类单回路诠释学循环为基本单位的诠释学卫星网络,其体现是整个西医专业的医学研究、临床实践和医学传承；而医学研究就是医理者此在本身的存在方式；临床实践就是医疗者此在本身的存在方式；医学研究的总和与临床实践的总和的叠加就是医学传承,是整个西医专业的存在方式。又从临床实践、知识体系、医学传承三个不同层面与中医进行了比较,发现中西医学的差异,来源于思维方式的差异。结论：本研究课题摆脱以往仅将思维运作时的共相抽出并以此作为对中医思维方式的一种解读,而要求以一种恰当的方法即哲学诠释学的原理去研究中医的思维方式。这一要求,通过回归中医思维方式这一事情本身的发生、发展而已基本达到了；也正因为通过了对效果历史的对话,使途经的认识论、本体论、中西医学、中西医学史、中西思想史和中西历史等多方面相关的问题都这样或那样地得到审视,并各就其位地蕴涵于结论那种诠释学循环所体现的时间性当中。在中西思维通约之处尚待发掘的时候,由于中西医学自身的临床实践、知识体系、医学传承都源自于各自独特的思维方式这一原点,所以,如硬以对方的思维方式为自身固有的临床实践、知识体系、医学传承作出调整、转化,或以科学方法对中医诸多范畴进行研究,只会是徒劳无功的。故面对现代医学的冲击,中医无须妄自菲薄,且中医在临床实践、知识体系、医学传承等方面均有其独特之处,绝对有进一步深化的空间,可为将来解决中医面对现代医学的误解和批评带来更有力的回应。更多还原

【Abstract】 ObjectiveAlthough there are many results from the studies of the Chinese medicine’s mode of thinking, they are fragmented and disconnected. As such, when Chinese medicine theories are misinterpreted and criticized from the Western medicine’s point of view, there is hardly any reservation from the Chinese medicine profession. On the contrary, the Chinese medicine profession turns away from the traditional mode of thinking and employs the so-called scientific methods to steer the studies of the profession. As this has become an imminent problem about the future of the entire Chinese medicine profession, this study is initiated in an attempt to solve this problem by interpreting the Chinese medicine’s mode of thinking in a more appropriate manner.MethodsThe methods employed by this studyTo get to know it from a historical point of view, Chinese medicine’s mode of thinking becomes an inheritance and is carried and manifested by clinical practices, clinical records and medical theories. As Chinese medicine’s mode of thinking is an inheritance, to study it we need to go beyond the domain of natural science and apply the principles of philosophical hermeneutics, with which a study plan for interpreting the Chinese medicine’s mode of thinking can be drawn up to include six experienced historical dialogues of three different levels. They are (1) the background of the formation of Huangdi Neijing’ s mode of thinking,(2) the use of Huangdi Neijing’s mode of thinking,(3) the development of Huangdi Neijing’s mode of thinking,(4) the contemporary challenges of Huangdi Neijing’s mode of thinking,(5) clinical records, and (6) clinical practices. While the former four belong to the theoretical level, the latter two belong to the clinical record level and clinical practice level respectively. Since the above study plan is too large to handle in one-go, this study will only focus on the interpretation of the Chinese medicine’s mode of thinking at the theoretical level, in an attempt to reach a phased result that is both academic and inheritable.The fore-value before the start of the interpretationAccording to the principles of philosophical hermeneutics, any interpretation starts with a fore-value, which is derived from the fore-comprehension of what have been known about the object to be interpreted.There are two basic types of mode of thinking, namely abstract thinking (or conceptual thinking) and yixiang thinking. The former contains a four-stage process using concepts to represent the ready-made, static and confirmed matters of the world. The latter contains a five-stage process using yixiang to represent the emerging, dynamic and possible matters of the world.Based on the fore-comprehension about the Chinese medical theories in Huangdi Neijing which are thought to be structured using yixiang, the fore-value before the start of the subject interpretation would be set as yixiang thinking.The background of the formation of Huangdi Neijing’s mode of thinkingFrom the revisit of the history, culture, thoughts and thinking from the prehistoric period of China to the Han dynasty, it is found that the traditional Chinese thoughts and almost all knowledge at that time including Chinese medicine had been influenced by the cosmo-human relationship and the yixiang thinking that developed along with. As such, the authors of Huangdi Neijing must have been influenced by the same cosmo-human relationship and the yixiang thinking that developed along with, especially when its contents have already been proved so by many contemporaries.The use of Huangdi Neijing’s mode of thinking The authors of Huangdi Neijing studied human life phenomenon from a motioned point of view. Inside human body, the combined motion of physical and non-physical objects manifests (a) as functions like viscera,(b) as information like meridians, or (c) as states like qixuejinye. All of them are yixiangderived from the process of yixiangthinking and developed into viscera doctrine, meridians doctrine and qixuejinye doctrine using the terms of qi, yi-yang and the Five Elements.Patterned motions of qixue manifest as human life phenomena or symptoms. Through yixiang thinking, one can observe these phenomena or symptoms and realize that there is a momentum representing the composite patterned motions of qixue. To a certain extent of a situation, momentum is regarded as a norm, and whatever interfering the norm is regarded as a variation. As long as the variation has not caused any irreversible change of the norm, the norm presides over the situation. This type of norm-variation relationship is a commonplace in human life phenomena. If healthy growth is a norm, then any difference in physique and disposition would be a variation. If that difference is too much such that healthy growth is affected, then disorder results. If disorder of human life phenomena is a norm, then any secondary associated symptom would be a variation. If that difference is too much such that disorder is affected, then healthy growth would be restored, or different kind of disorder would be developed or death would result. If orderly seasonal change is a norm, then any disorderly climatic change would be a variation, which is usually a common cause of human illness. As far as medical treatment is concerned, to regulate a momentum of a disorder, an anti-momentum is proposed in an attempt to cancel out each other so that healthy growth is restored.The entire Chinese medicine theory established by yixiang would be eventually transformed into text. The text can be considered as an interpretation of patterned motions of qixue of human life and assists one to use yixiang thinking to deal with the norm-variation problems occur in human life.The development of Huangdi Neijing’s mode of thinkingAs part of the traditional Chinese culture, Chinese medicine is always influenced by it. The structures of the universe advocated by Huang-Lao Daoism, Confucianism and Neo-Confucianism were all established based on the cosmo-human relationship and the yixiang thinking that developed along with, encompassing a knowledge system that represents the emerging, dynamic and possible matters of the world. It was the same kind of structure that Chinese medicine borrowed to form the Chinese medicine theory which established a spatial-temporal framework with viscera as it center that opened up beyond human body and into the entire universe.The Chinese medicine yixiang thinking model first develops inside the Chinese medicine practitioner’s mind in terms of psychological language for the purpose of clinical practice on the scene. It is then transformed into text in terms of natural language for the purpose of communication and inheritance off the scene. This on and off the scene usage and passing on has made the Chinese medicine yixiang thinking model itself an inheritance, which constantly under interpretation through the abovementioned theory-application cycle.As an inheritance, the Chinese medicine yixiang thinking model had in the Song Dynasties developed into a structure that dominated by the viscera xing-medical treatment sub-system and then the viscera xiang-nourishment therapy sub-system, with reference to the yunqi sub-system and the qiwei sub-system. Within the viscera xiang-medical treatment sub-system, the studies of the classical texts were more related to the viscera xiang side while the publishing of prescriptions were more related to the medical treatment side. There were also medical theory-cum-prescription texts that represented the medium. Besides, clinical division into specific subjects like internal medicine, external medicine, pediatrics, gynecology, orthopedics and traumatology, otorhinolaryngology and acupuncture and moxibustion were gradually derived from the Chinese medicine yixiang thinking model. Starting from the Jin Yuan Dynasties, different kinds of Chinese medical schools of thoughts had been developed as a result of the advanced development of the Chinese medicine yixiang thinking model. Such schools of thoughts usually manifested in the Chinese medicine practitioner’s train of thoughts during clinical practice.On or before the Song Dynasties, the Chinese medicine yixiang thinking model can be considered as a period of knowledge accumulation and formation while from the Jin Yuan Dynasties to the late Qing Dynasty, the Chinese medicine yixiang thinking model can be considered as a period of knowledge enhancement and advancement. However, from the late Qing Dynasty onward, such thinking model has been challenged by another type of thinking model that has long been developed in the other parts of the world.ResultsThe interpretation of the Chinese medicine’s mode of thinking yielded in this study is:the Chinese medicine’s mode of thinking is yixiang thinking, which, in nature, is a hermeneutic cycle web based on a dual-circuit hermeneutic cycle manifested as all clinic practices and medical inheritances of the entire Chinese medicine profession. All clinical practices and medical inheritances as a whole is the existential mode of the Chinese medicine profession.With this fore-understanding, we turn to face the challenges imposed by the Western medicine.The contemporary challenges of Huangdi Neijing s mode of thinkingAfter revisit of the Western history, culture, thoughts and thinking from the prehistoric period to the present time, we are also given the interpretation of the Western medicine’s mode of thinking:the Western medicine’s mode of thinking is abstract (or conceptual) thinking, which, in nature, is a hermeneutic satellite web based on two separate single-circuit hermeneutic cycles manifested as all medical researches, clinical practices and medical inheritances of the entire Western medicine profession. The combination of all medical researches and all clinical practices is the medical inheritance itself, which is the existential mode of the Western medicine profession.Besides, comparisons were also conducted between Chinese and Western medicines in terms of clinical practice, knowledge model and medical inheritance. It is found that their differences are originated from the modes of thinking.ConclusionThis study did not use the traditional methods that abstract common concepts from the phenomena to establish its interpretation of Chinese medicine’s mode of thinking. Instead, a better method applying the principles of philosophical hermeneutics was adopted, and results were successfully obtained by examination of the Chinese medicine’s mode of thinking through primordial experience of it along its entire experienced history, where all related issues such as epistemology, ontology, Chinese and Western medicine, histories of Chinese and Western medicine, histories of Chinese and Western thoughts and Chinese and Western histories were inspected and properly addressed and implied by the hermeneutic cycle web and hermeneutic satellite web interpreted.While awaiting a common ground commensurable to both Chinese and Western modes of thinking and since clinical practice, knowledge model and medical inheritance are developed uniquely and exclusively from either Chinese or Western mode of thinking, it is futile to apply either mode of thinking to another in an attempt to adjust and transform domains of another including employing scientific methods to steer the future development of Chinese medicine. On the contrary, we should learn the strength of Chinese medicine better. Through continuous enhancement and improvement on our clinical practice, knowledge model and medical heritance, we will be able to address against the misinterpretation and criticism from the Western medicine’s point of view in a convinced manner.更多还原