核心提要：贝志城通过远程诊断帮助协和医生挽救了朱令的生命，他自己却在第二年被北大“劝退”。这里面的全部秘密就在于一个关键问题：时间限制性。尼罗河对证据的分析表明，所谓“远程诊断“不过是一个明修栈道的先知神话。

在《诊断骗局之鱼目混珠》一文中，尼罗河揭示贝志城在中央电视台文献记录片中展示的“远程诊断”不过是他自己从教科书上摘录的内容。人们不禁要问，既然贝志城声称手里有上千份电邮回复，其中30%作出了铊中毒的正确诊断。一个绝对数字是84份邮件作出了铊中毒的正确诊断。拿出一份邮件来给大家见识一下这个“正确诊断”应该是没有问题的。贝志城之所以不能出示“正确诊断”并不是因为他手里没有这样的东西，而是他遇到一道绕不过去的坎：时间限制性。注意下面这段对话（中央电视台文献记录片《朱令的12年》）：

贝志城：十号发了那是个周一，周三我就给朱令他爸爸打电话说，我看到提问里还有说是铊中毒。

贝志城：很多医生很激烈地发表意见，说一定要作这个化验，因为她的症状太像铊中毒了。

朱令父亲：贝志城给我打了个电话，说有人觉得是不是就是铊中毒。

朱令母亲：他（贝志城）说，阿姨你是怎么了，这么多人都说是铊中毒，你为什么就不去化验。 

一个极不寻常又一直被公众忽略的是贝志城中出现的一个费解的口误。贝志城：十号发了那是个周一，周三我就给朱令他爸爸打电话说，我看到提问里还有说是铊中毒。本来贝志城应该对朱令父亲说回信里有人说是铊中毒，却说成了“提问里还有说是铊中毒”。事实上这并非口误。贝志城在北京时间1995年4月12日5点48分，也就是4月10日发出第一份求救信后不到35小时就第二次发出求救信，并且在主题栏中赫然作出了诱导性提示：

Urgent!!! Need diagnostic advice for sick friend (?thallium poisoning)

可以断定的是主题栏中出现的这个诱导性问题并不是在这份文件的传递过程中人为添加的。朱令是不是铊中毒？用意非常明显就是要诱导国外医生作出铊中毒的诊断。从David Nelson 医生回信（附件3）回信的内容来看。第一句就是对这个问题的直接回答：ZHU LINGS PROBLEMS SOUND LIKE THALLIUM POISONING。而且回信全文都是围绕铊中毒，完全没有考虑任何鉴别诊断。Nelson医生发信地址后缀为bc.ca。是加拿大British Columbia。当地时间1995年4月14日星期四21点（Thu, 13 Apr 1995 21:27:10）是北京时间4月14日星期五中午12点。这个时间离贝志城用电话向朱令父亲报警已经过去了两天。

尼罗河本人曾经与Nelson医生工作的医院取得联系。试图求证求证两件事情。第一，Nelson医生没有讨论任何鉴别诊断是否因为求助信的主题的诱导。第二，在网络上从来没有人看到过这份有明显诱导性问题的第二封求救信。Nelson医生是否还保留有原始邮件。贝志城在第二份求救信中究竟写了什么内容。但是这位Nelson医生早已退休，不知去向。

一个无法改变的事实是，贝志城在48小时之内（1995年4月10日到12日）就锁定了铊中毒诊断。而他手里根本就没有在48小时之内回复的“正确诊断”。这就是为什么他不敢当众展示“正确诊断”的关键。

在The First Large-Scale International Telemedicine Trial to China: ZHU Ling’s Case 网页上列出了84名专业人员作出了正确的诊断。其中，在4月12日之前作出正确诊断的人名单如下 （原始文件拷贝见附件1）：

1. Steve Cunnion, MD, PhD, MPH, the Uniformed Services University of Health 

Sciences

2. Frank Bia, MD, MPH, Professor of Medicine, Yale University

3. Dr. Neil Kay

4. John M. Friedberg, M.D., Neurologist, Berkeley, CA 94705

via Robert A. Fink, M. D., F.A.C.S., Neurological Surgery

5. Dr. Martin Wolfe, Tropical Medicine Consultant.

via John Aldis, M.D, MPH, FACS, U.S. State of Department

6. Dr. Aldis, M.D., AAFP, MPH & Tropical Medicine, U.S. State Department

7. Prof. Leslie H Bernstein

via Carole Shmurak

8. Jacquie Heller 

根据贝志城们的记载，美国加州神经外科医生Robert A. Fink作出正确诊断的时间是4月11日。尼罗河查到了一篇Robert A. Fink医生本人撰写的文章《The Tao of the Internet》（全文拷贝见附件2）。从文章中可以清楚地看到，美国太平洋夏令时间4月11日也就是北京时间4月12日，他才在他的网络邮箱中看到从北京大学发出的求救信。 美国时间4月12日，也就是北京时间4月13日，Fink 医生还在与协和医院联系获取朱令的病情进展和相关检查信息。Fink 医生根本不可能在北京时间4月12日之前就做出铊中毒的诊断。

2013年，尼罗河找到了上述八位医生中的三位医生，通过电邮和电话取得了联系。只有Cunnion医师明确作出了铊中毒的诊断，他曾经在一家化学试剂公司工作，经历过铊中毒所以他一看到朱令的病情第一个想到的就是铊中毒。但是Cunnion医生没有保存当年的电子邮件也不能回忆回复电邮的时间。尼罗河直接联系的其他两位医师有一位明确表示自己没有考虑到铊中毒。另一位在同行的提示下考虑到铊中毒，但是并没有明确铊中毒诊断，而是作为多个鉴别诊断之一提供参考。这位医生在电邮中回忆当时的情况写道：“提供诊断意见的邮件如潮水一般涌来，我们几乎被这些冗长的邮件淹没。当时提出了很多很多可能的诊断，而且相当大的一部分是愚蠢的想法。根本不要指望看到铊中毒从各种其他鉴别诊断的建议中浮出水面。 ” 。

必须说明这位被邮件淹没的医生本人深度参与了朱令案的诊断过程。他介入朱令案诊断过程的时间是贝志城发出求救信的一周之后。也就是说，一个资深专业人员对7天以来的回复邮件进行判读之后依然无法看到铊中毒从各种诊断建议中露出水面。一个力学系的大学二年级学生凭什么从不到48小时的回信中就如此精准地判定了铊中毒。事实上，贝志城“考虑到”铊中毒的时间只有不到35小时。

网名为“我是你的真相”的作者在xys发表文章《远程诊断——童话还是骗局？》。通过对1995年5月11日到19日9天的104封电邮进行了统计。发现在36封第一次回复，并出自己的诊断建议的邮件中，。 thallium出现了3次，与汞，脊髓灰质炎，肉毒，自体免疫，频度是相同的。按诊断病名频次高低分布排列如下：放射反应(Radiation/Radioactive)和格林-巴利综合征(Guillain-Barre)，都达到8次，其中格林-巴利综合症与协和医院诊断结果相同。而模糊的认为化学品中毒(Chemical)和重金属中毒(Heavy Metal)的分别有5次和4次。认为红斑狼疮或系统性红斑狼疮(Lupus)的也有4次。这篇文章虽然没有拿到最初几天的邮件回复，但是这些邮件客观反映了专业人员面对复杂病例的鉴别诊断方式。

（http://www.xys.org/xys/ebooks/others/science/dajia14/zhuling10.txt ）

不论是寻访当年参与诊断的医生，还是查证当年作出诊断的文件，贝志城所谓在两天之内有八位医生作出了正确诊断，两周之内有48份邮件作出正确诊断，完全是经不起客观查证的谎言。

一条完整的证据链已经形成。贝志城从一开始就知道朱令病情的真实原因。看到朱令中毒的惨状，心理防线受到巨大的冲击，只剩下拔腿逃跑的念头。或出于良心的不安，或出于对杀人偿命的畏惧，为了保全朱令的性命，贝志城设计了远程诊断的骗局。希望假借“国外医生”之口告诉协和医生朱令病情的真相。事有不济，医生的诊断思维不可能超出客观认知能力的限制。朱令当时已经危在旦夕，贝志城不得不直接以诱导提问方式寻求国外医生尽快提供铊中毒的诊断。而且伪造了在两天之内有8位医生作出“正确诊断”的传奇。

附件1：

The First Large-Scale International Telemedicine Trial to China:

ZHU Ling’s Case

http://web.archive.org/web/20000816192018/http://www.radsci.ucl

The following is a list of 84 persons who made the correct diagnosis by 

themselves or by their friends who were consulted in the order of being 

received by Beijing University students between April 10 and April 26, 1995.

4/10        Steve Cunnion, MD, PhD, MPH

the Uniformed Services University of Health Sciences 

            SWEET@utkvx.utk.edu 

4/11        Andi/Cleveland State Univ. Ohio

            Frank Bia, MD, MPH, Professor of Medicine, Yale University

            Dr. Neil Kay

            John M. Friedberg, M.D.,  Neurologist, Berkeley, CA 94705

                via Robert A. Fink, M. D., F.A.C.S., Neurological Surgery

            Dr. Martin Wolfe, Tropical Medicine Consultant.

                via  John Aldis, M.D, MPH, FACS, U.S. State of Department

            (Dr. Aldis, M.D., AAFP, MPH & Tropical Medicine, U.S. State

            Department, was the doctor for U.S. Embassy to China 1989-93.

            He knew many doctors personally at PUMC and he actually saw

            Zhu Lingling at PUMC in March. He has been highly involved

            in the case and coordinated some of the international efforts.) 

            Prof. Leslie H Bernstein

                via Carole Shmurak

            Jacquie Heller 

附件2：

The Tao of the Internet

by Robert A. Fink, M. D., F.A.C.S.

On April 11, 1995, I found in my Internet mailbox a message, in “fractured

” English, from a young graduate student at Beijing University in China. It

was a message of desperation. It concerned the plight of a fellow graduate 

student in chemistry, a 21-year-old woman who lay in the Intensive Care Unit

of the University Hospital of Peking Union Medical College (PUMC). PUMC is 

a medical school established by the Rockefeller family in the early part of 

the twentieth century, and, as the model for Abraham Flexner’s seminal 

report on medical education, perhaps, “the most American of non-American 

medical schools”. A reconstruction of the young woman’s case history to 

that date is as below:

In early December, 1994, the patient complained of abdominal pain, cramping,

and extremity pain. Extensive tests, including autoimmune studies, thyroid 

tests, pelvic and abdominal untrasound, skull x-rays, and bone marrow 

examination were all normal. It was noted that the patient had some 

abnormalities of her nails, but this was not reported further. She was 

treated with “traditional Chinese medicine” and was discharged, improved. 

She subsequently returned to work (in a chemistry lab); we still do not know

what chemicals she was working with. An “afterthought” was listed in the 

report, this a piece of data which was to become critical in the diagnosis 

of this woman’s condition; and that was the fact that, shortly after the 

onset of the abdominal symptoms on December 8, 1994, the patient’s scalp 

hair fell out, and she “became bald”.

After a period of improvement (and some re-growth of hair), the patient 

returned to the hospital with signs of peripheral neuropathy in the 

extremities, rapidly progressive disturbances in sensorium (and recurrent 

alopecia), developed multiple cranial nerve palsies, became comatose, and 

required a ventilator. She also showed muscular spasms, described as “

oculogyric crises”, and a tracheostomy was performed. Lumbar puncture and 

MRI studies of the brain were normal, and studies for viruses, including 

Lyme Disease, were negative. The patient was treated with “shotgun” 

antibiotics with no improvement.

At that point, the author corresponded with the sender of the “distress 

message”. I learned that a number of other physicians, including people 

from the United States, Canada, Great Britain, Singapore, Thailand, 

Indonesia, and other countries, were also communicating with the student-

sender and several other students at the University. The students in China 

have Internet connections but, (as we later learned), hospitals and 

physicians do not. We were forced to engage in our later communication with 

the medical professionals either by facsimile, which is tightly controlled 

by the Chinese Government; or by sometimes circuitous person-to-person 

connections. Information transmitted over the Internet to the students often

did not reach the medical professionals who were treating the patient. This

was due to the complex hierarchy of the Chinese culture, in which accepting

information from “students” is almost as alien to Chinese professionals 

as is dealing with “outsiders”. This lack of direct communication has 

proven to be the most significant negative factor in this equation.

One of the earliest possible diagnoses which came to the mind of the author 

(and several others of the “outsiders”) was that of heavy metal poisoning 

(the alopecia was the “clue”). We asked if tests had been performed for 

heavy metals and were assured that such had been done early on. We later 

discovered that these consisted only of a screen for arsenic!

By March 16, 1995, the patient had been in coma for several weeks; and, 

despite normal cerebrospinal fluid findings, a diagnosis of Guillain-Barre 

syndrome was made by the Chinese physicians. By April 12, 1995, the patient

’s condition had not changed, and a repeat lumbar puncture revealed an 

elevated protein (248 mg.%) and 6 leukocytes. The impression of Guillain-

Barre syndrome was reinforced, despite messages from the “outsiders” that 

this picture was not consistent with Guillain-Barre.

At about this same time, the author and John W. Aldis, M.D., a physician 

working in the U. S. State Department, and formerly the Embassy physician in

Beijing, conceived of the idea of thallium poisoning, this after Dr. Aldis 

was sent an article by Rose Miketta, M. D., a physician with Searle 

Pharmaceutical Company, explaining the neurotoxic effects of thallium. We 

again suggested that the patient be checked for thallium poisoning. This 

recommendation was further backed by others, including Dr. David Bullimore 

at St. James’ Hospital in England, and several other p hysicians in the 

United States. Yet, two weeks passed before the Chinese physicians decided 

to perform the thallium study. It required an intervention by personnel at 

the American Embassy in Beijing, and personal contacts between Dr. Aldis and

several o f the PUMC doctors (whom Dr. Aldis had known from his days in 

Beijing), and faxes of articles directly to the hospital, before the test 

for thallium was finally run. The results were striking. The patient had 

levels of thallium in blood, urine, cerebrosp inal fluid, hair, and nails 

which were more than 50 times higher than “normal”! As to the source of 

the thallium, this remains unknown; but certain laboratory chemicals contain

thallium; and, in the Orient, there are several industrial compounds (

including several brands of rat poison) which contain thallium (its use is 

generally outlawed in the western world).

Once the diagnosis was established, the next problem was encountered. 

Several of us, using the Internet and other online databases, searched the 

literature for the optimum method of removing thallium from the body. A 

number of methods were cited; but to xicologists at the New York and Los 

Angeles Poison Control Centers felt that the most effective treatment was 

that of administration of the dye Prussian Blue (ferric ferrocyanide) and 

renal hemodialysis, with addition of potassium chloride. Then came the 

problem of obtaining the Prussian Blue (a common industrial chemical which 

was eventually found in China). Underlying this difficulty was the fact that

, once again, advice from “outsiders” was suspect by the Chinese.

Finally, after many phone calls, faxes, and other communications (the 

doctors at PUMC would not deal with the students, who had Internet 

connections), including the involvement of the patient’s family (several of

whom were known political figures locally) , the Prussian Blue-hemodialysis

regimen was started on May 5, 1995, this almost one month from the initial 

proposal of the diagnosis of thallium intoxication and some forty days after

the patient had lapsed into coma and had become apneic.

I wish that I could report a “happy ending” here. The patient responded 

rapidly to the treatment, and, within 15 days after the institution of 

treatment, the patient’s thallium levels in blood, urine, and cerebrospinal

fluid had decreased to near-zero (although certain other tissues, such as 

nails and hair, will retain the metal for many weeks and will slowly “leach

out”). Sadly, the patient’s neurological condition has not improved to a 

significant degree. She now has been partially weaned from the ventilator, 

and seems to recognize her parents; but she does not as yet have full 

consciousness, nor does she exhibit much in the way of voluntary or 

purposeful activity. The long period of brain intoxication in this case 

appears to be the reason for her lack of further progress to date and the 

prognosis for recovery remains guarded.

In recent years, there has been geometric growth in the use of online 

communication in medicine. The new field of “Telemedicine” is rapidly 

being advanced in the developed countries, with computer review of case 

histories, imaging studies (many of which are digital in their native form),

and other medical data becoming almost “routine” in making judgments, for

example, as to the transport of seriously ill or injured patients to 

tertiary medical centers. In our own area, patients are transported on a 

daily basis, from small facilities out in the “hinterland” to major urban 

medical centers. Physicians at outlying hospitals have, through a simple 

computer/modem connection, access to specialists and centers with advanced 

technology. The growing use of ISDN (Integrated Services Digital Network) 

telephone lines has made the transfer of complex information, including full

-resolution MRI and CT scans, into a rapid and seamless procedure. The 

global Internet renders such “connectivity” a relatively inexpensive 

reality to be enjoyed by health care professionals and patients throughout 

the world.

Despite this availability of technology (and, in the case of this 

unfortunate student), however, the finest advances in global communication 

cannot surmount centuries of tradition and cultural differences. In this 

case, the cultural differences delayed implementation of the large volume of

collective knowledge which was brought to bear on behalf of a young woman; 

and sadly in this instance, was probably “too little and too late”. As 

with other problems in this world, it still comes down to the “human factor

”.

As we advance the cause of “Telemedicine” and other interactive 

technologies, we must never lose sight of the fact that, behind these 

wonderful machines are the minds and hearts, and prejudices, of the human 

beings who run them. It is in this “human arena” where we need to place 

our educational emphasis, so that the marvels of the modern digital age can 

be used for the advancement of our species and of the world as a whole.

AUTHOR’S NOTE:

This paper is dedicated to Zhu Lin, the 21-year-old student who is the 

subject of the case report. Acknowledgement is also gratefully made to John 

W. Aldis, M. D. (U. S. State Department); Xin Li (telemedicine fellow at 

UCLA Medical Center); Dr. Ashok Ja in (USC Department of Emergency Medicine 

and Los Angeles Poison Control Center); Dr. R. Hoffman and his colleagues (

New York City Poison Control Center); Dr. David Bullimore (University of 

Leeds, England); and the myriad other people who labored on behalf of a 

young woman, critically ill halfway across the world.

http://www.rafink.com/tao.php 

附件3，加拿大医生David Nelson 的电邮。

Urgent!!! Need diagnostic advice for sick friend (?thallium poisoning)

In article  eye…@mindlink.bc.ca (David Nelson) writes:

> From: eye…@mindlink.bc.ca (David Nelson)

> Subject: Re: Urgent!!! Need diagnostic advice for sick friend

> Date: Thu, 13 Apr 1995 21:27:10

> In article  ca…@mccux0.mech.pku.edu.cn (Cai Quanqing) writes:

>> Path: news.mindlink.net!agate!hpg30a.csc.cuhk.hk!linuxguy.pku.edu.cn!

mccux0!caiqq

>> From: ca…@mccux0.mech.pku.edu.cn (Cai Quanqing)

>> Newsgroups: sci.med,sci.med.diseases.cancer,sci.med.immunology,sci.med.

informatics,sci.med.nursing,sci.med.nutrition,sci.med.occupational,sci.med.

pharmacy,sci.med.physics,sci.med.psychobiology,sci.med.radiology,sci.med.

telemedicine,sci.med.transcription

>> ci.med.vision

>> Subject: Urgent!!! Need diagnostic advice for sick friend

>> Date: 11 Apr 1995 19:48:59 GMT

>> Organization: Peking Universary,China

>> Lines: 106

>> Message-ID:

>> NNTP-Posting-Host: 162.105.195.2

>> X-Newsreader: TIN [version 1.2 PL2]

>> Xref: news.mindlink.net sci.med:119360 sci.med.diseases.cancer:1660 sci.

med.immunology:1247 sci.med.informatics:1918 sci.med.nursing:5238 sci.med.

nutrition:23756 sci.med.occupational:3075 sci.med.pharmacy:8698 sci.med.

physics:3488 sci.med.psychobiology:

>> 35 sci.med.radiology:1875 sci.med.telemedicine:4993 sci.med.transcription

:1255 sci.med.vision:3680

ZHU LINGS PROBLEMS SOUND LIKE THALLIUM POISONING THE COMBINATION OF ACUTE 

HAIR

LOSS, GASTROINTESTINAL AND NEUROLOGICAL PROBLEMS IS ALMOST PATHOGNOMONIC.

UNLESS SHE WORKSWITH THALLIUM (AS IN PRODUCING OPTICAL LENSES) THEN IT IS

LIKELY THAT SHE ISBEING POISONED DELIBERATELY. PLEASE PROVIDE ME WITH 

FOLLOWUP.

YOU MAY BE INTERESTED IN REFERENCE: FELDMAN D, LEVISOHN DR “ACUTE ALOPECIA:

CLUE TO THALLIUM TOXICITY” PEDIATRIC DERMATOLOGY 10910;29-31 1993 MARCH.

ABSTRACT: COMBINATION OF RAPID DIFFUSE ALOPECIA, NEUROLOGICAL AND

GASTROINTESTINAL DISTURBANCE IS PATHOGNOMONIC FOR THALLIUM POISONING. THE 

HAIR

MOUNT SHOWED A TAPERED OR BAYONET ANAGEN HAIR WITH BLACK PIGMENTATION AT THE

BASE MAY BE HIGHLY DIAGNOSTIC BEFORE THE ONSET OF ALOPECIA. WE SAW A 10 YEAR

OLD BOY WHO SUFFERED FROM THALLIUM POISONING (END ABSTRAST)

YOU SHOULD BE ABLE TO DETECT THALLIUM IN THE HAIR WITH A MASS SPECTROMETER I

WOULD HAVE THOUGHT.

HOPE THIS IS OF HELP

- show quoted text -

- show quoted text -

- show quoted text -

> I will attempt to forward your message to the eye specialists and

> neuro-ophthalmologists of north america to see if anyone can be of

> assistance.

> Best Wishes,

> David Nelson, M.D.