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An emergency surgical procedure in which accidental excessive hypothermia was induced is described. Temperature drop at a rate greater than normal led to investigation which revealed improper setting of a hypo-hyperthermia machine. A simple and effective modification was made to the hypo-hyperthermia machines to reduce the likihood of the repetition of this event. Evaluation of the modified unit revealed no significant degradation of performance. Physiological effects of hypothermia are also described.