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清華投毒案——診斷騙局之神話先知

作者:尼羅河水天上來  於 2016-3-1 00:39 發表於 最熱鬧的華人社交網路--貝殼村

通用分類:熱點雜談

核心提要:貝志城通過遠程診斷幫助協和醫生挽救了朱令的生命,他自己卻在第二年被北大「勸退」。這裡面的全部秘密就在於一個關鍵問題:時間限制性。尼羅河對證據的分析表明,所謂「遠程診斷「不過是一個明修棧道的先知神話。

在《診斷騙局之魚目混珠》一文中,尼羅河揭示貝志城在中央電視台文獻記錄片中展示的「遠程診斷」不過是他自己從教科書上摘錄的內容。人們不禁要問,既然貝志城聲稱手裡有上千份電郵回復,其中30%作出了鉈中毒的正確診斷。一個絕對數字是84份郵件作出了鉈中毒的正確診斷。拿出一份郵件來給大家見識一下這個「正確診斷」應該是沒有問題的。貝志城之所以不能出示「正確診斷」並不是因為他手裡沒有這樣的東西,而是他遇到一道繞不過去的坎:時間限制性。注意下面這段對話(中央電視台文獻記錄片《朱令的12年》):

貝志城:十號發了那是個周一,周三我就給朱令他爸爸打電話說,我看到提問里還有說是鉈中毒。
貝志城:很多醫生很激烈地發表意見,說一定要作這個化驗,因為她的癥狀太像鉈中毒了。
朱令父親:貝志城給我打了個電話,說有人覺得是不是就是鉈中毒。
朱令母親:他(貝志城)說,阿姨你是怎麼了,這麼多人都說是鉈中毒,你為什麼就不去化驗。 

一個極不尋常又一直被公眾忽略的是貝志城中出現的一個費解的口誤。貝志城:十號發了那是個周一,周三我就給朱令他爸爸打電話說,我看到提問里還有說是鉈中毒。本來貝志城應該對朱令父親說回信里有人說是鉈中毒,卻說成了「提問里還有說是鉈中毒」。事實上這並非口誤。貝志城在北京時間1995年4月12日5點48分,也就是4月10日發出第一份求救信后不到35小時就第二次發出求救信,並且在主題欄中赫然作出了誘導性提示:

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

可以斷定的是主題欄中出現的這個誘導性問題並不是在這份文件的傳遞過程中人為添加的。朱令是不是鉈中毒?用意非常明顯就是要誘導國外醫生作出鉈中毒的診斷。從David Nelson 醫生回信(附件3)回信的內容來看。第一句就是對這個問題的直接回答:ZHU LINGS PROBLEMS SOUND LIKE THALLIUM POISONING。而且回信全文都是圍繞鉈中毒,完全沒有考慮任何鑒別診斷。Nelson醫生髮信地址後綴為bc.ca。是加拿大British Columbia。當地時間1995年4月14日星期四21點(Thu, 13 Apr 1995 21:27:10)是北京時間4月14日星期五中午12點。這個時間離貝志城用電話向朱令父親報警已經過去了兩天。

尼羅河本人曾經與Nelson醫生工作的醫院取得聯繫。試圖求證求證兩件事情。第一,Nelson醫生沒有討論任何鑒別診斷是否因為求助信的主題的誘導。第二,在網路上從來沒有人看到過這份有明顯誘導性問題的第二封求救信。Nelson醫生是否還保留有原始郵件。貝志城在第二份求救信中究竟寫了什麼內容。但是這位Nelson醫生早已退休,不知去向。

一個無法改變的事實是,貝志城在48小時之內(1995年4月10日到12日)就鎖定了鉈中毒診斷。而他手裡根本就沒有在48小時之內回復的「正確診斷」。這就是為什麼他不敢當眾展示「正確診斷」的關鍵。

在The First Large-Scale International Telemedicine Trial to China: ZHU Ling』s Case 網頁上列出了84名專業人員作出了正確的診斷。其中,在4月12日之前作出正確診斷的人名單如下 (原始文件拷貝見附件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 

根據貝志城們的記載,美國加州神經外科醫生Robert A. Fink作出正確診斷的時間是4月11日。尼羅河查到了一篇Robert A. Fink醫生本人撰寫的文章《The Tao of the Internet》(全文拷貝見附件2)。從文章中可以清楚地看到,美國太平洋夏令時間4月11日也就是北京時間4月12日,他才在他的網路郵箱中看到從北京大學發出的求救信。 美國時間4月12日,也就是北京時間4月13日,Fink 醫生還在與協和醫院聯繫獲取朱令的病情進展和相關檢查信息。Fink 醫生根本不可能在北京時間4月12日之前就做出鉈中毒的診斷。

2013年,尼羅河找到了上述八位醫生中的三位醫生,通過電郵和電話取得了聯繫。只有Cunnion醫師明確作出了鉈中毒的診斷,他曾經在一家化學試劑公司工作,經歷過鉈中毒所以他一看到朱令的病情第一個想到的就是鉈中毒。但是Cunnion醫生沒有保存當年的電子郵件也不能回憶回複電郵的時間。尼羅河直接聯繫的其他兩位醫師有一位明確表示自己沒有考慮到鉈中毒。另一位在同行的提示下考慮到鉈中毒,但是並沒有明確鉈中毒診斷,而是作為多個鑒別診斷之一提供參考。這位醫生在電郵中回憶當時的情況寫道:「提供診斷意見的郵件如潮水一般湧來,我們幾乎被這些冗長的郵件淹沒。當時提出了很多很多可能的診斷,而且相當大的一部分是愚蠢的想法。根本不要指望看到鉈中毒從各種其他鑒別診斷的建議中浮出水面。 」 

必須說明這位被郵件淹沒的醫生本人深度參與了朱令案的診斷過程。他介入朱令案診斷過程的時間是貝志城發出求救信的一周之後。也就是說,一個資深專業人員對7天以來的回復郵件進行判讀之後依然無法看到鉈中毒從各種診斷建議中露出水面。一個力學系的大學二年級學生憑什麼從不到48小時的回信中就如此精準地判定了鉈中毒。事實上,貝志城「考慮到」鉈中毒的時間只有不到35小時。

網名為「我是你的真相」的作者在xys發表文章《遠程診斷——童話還是騙局?》。通過對1995年5月11日到19日9天的104封電郵進行了統計。發現在36封第一次回復,並出自己的診斷建議的郵件中,。 thallium出現了3次,與汞,脊髓灰質炎,肉毒,自體免疫,頻度是相同的。按診斷病名頻次高低分佈排列如下:放射反應(Radiation/Radioactive)和格林-巴利綜合征(Guillain-Barre),都達到8次,其中格林-巴利綜合症與協和醫院診斷結果相同。而模糊的認為化學品中毒(Chemical)和重金屬中毒(Heavy Metal)的分別有5次和4次。認為紅斑狼瘡或系統性紅斑狼瘡(Lupus)的也有4次。這篇文章雖然沒有拿到最初幾天的郵件回復,但是這些郵件客觀反映了專業人員面對複雜病例的鑒別診斷方式。
(http://www.xys.org/xys/ebooks/others/science/dajia14/zhuling10.txt )

不論是尋訪當年參與診斷的醫生,還是查證當年作出診斷的文件,貝志城所謂在兩天之內有八位醫生作出了正確診斷,兩周之內有48份郵件作出正確診斷,完全是經不起客觀查證的謊言。

一條完整的證據鏈已經形成。貝志城從一開始就知道朱令病情的真實原因。看到朱令中毒的慘狀,心理防線受到巨大的衝擊,只剩下拔腿逃跑的念頭。或出於良心的不安,或出於對殺人償命的畏懼,為了保全朱令的性命,貝志城設計了遠程診斷的騙局。希望假借「國外醫生」之口告訴協和醫生朱令病情的真相。事有不濟,醫生的診斷思維不可能超出客觀認知能力的限制。朱令當時已經危在旦夕,貝志城不得不直接以誘導提問方式尋求國外醫生儘快提供鉈中毒的診斷。而且偽造了在兩天之內有8位醫生作出「正確診斷」的傳奇。



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,加拿大醫生David Nelson 的電郵。
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.


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