attending one of the periodic "open houses" that are arranged at the DCIEM. Roy J. SHEPHARD, MD, PH D Professor of applied physiology Department of preventive medicine and biostatistics University of Toronto Toronto, Ont.
Dermoid cyst of the cecum To the editor: To date only three cases of dermoid cyst of the cecum have been reported in the literature. We report a new case of this rare entity.
A 53-year-old woman was admitted to hospital in July 1976 complaining of passing frank blood in the stools following intermittent episodes of melena. Her medical history was unremarkable apart from a hysterectomy and appendectomy performed in 1956. She also had had intermittent epigastric distress for more than 20 years. Rectal examination revealed blood but there were no other positive findings. Laboratory investigation gave the following values: hemoglobin, 9.2 g/dL; leukocyte count, 6.7 X 105/L; platelet count, 181 X 109/L; prothrombin time, 13 secodds; and partial thromboplastin time, 35 seconds. The appearance on sigmoidoscopic examination was normal to 18 cm and on colonoscopic examination normal to 100 cm although some difficulty was experienced in negotiating the cecum. Roentgenography of the gastrointestinal tract showed spasm at the duodenal bulb. In view of the history and findings a vagotomy and pyloroplasty were performed from which the patient made an uneventful recovery. Within the next 7 months the patient was readmitted to hospital on four separate occasions. On each of these occasions her complaint was the passage of melena stools but physical examination disclosed no abnormality. At various times she was subjected to gastroscopy, aortic angiography, colonoscopy and laparotomy when intraoperative endoscopy failed to reveal the source of the repeated hemorrhages. On one admission the hemoglobin concentration was only 8.5 g/dL and a blood transfusion was given. On the final admission, in February 1977, she was in shock from profuse rectal bleeding. After she had been resuscitated a hepatic flexure colostomy
was performed. One week later there was bleeding from the proximal opening of the colostomy. Colonoscopy of the proximal limb revealed several questionable hemorrhagic areas in the cecum but no definite bleeding site. A right hemicolectomy and an ileotransverse colostomy were performed subsequently. She made an uncomplicated recovery and has been free of symptoms since. Pathologic examination revealed an irregular polypoid mass 4 cm in diameter, 5 cm distal to the ileocecal valve. The cut surface showed an irregular cavity containing old blood coagulum. Histologic sections of the cecum taken through this mass showed marked infiltration of the wall by acute and chronic inflammatory cells. Several fissure tracks were present that extended to the serosal surface. On the serosal surface were fragments of a cyst composed of stratified squamous epithelium with keratinous differentiation. There was a considerable amount of blood within the cyst cavity. In some areas of the bowel wall there was a foreign body giant cell reaction apparently to the keratinous debris. Skin appendages were evident within the stratified squamous epithelium.
A review of the literature reveals only three similar cases. Gowdy,1 in 1956, reported the first case, in a 21year-old woman presenting with intestinal obstruction. In 1971 Kay2 reported a case of a 1-year-old girl who had two cecal cysts, one lined with epidermis accompanied by sebaceous glands and hair follicles, the other lined with gastric-type glands. A third case, reported in 1973,. was of a man aged 28 years who presented with a right lower quadrant mass, which, at laparotomy, was found to be a cecal cyst filled with sebaceous material and hair and lined by stratified squamous epithelium. All the authors agree that these cysts undoubtedly originated as a result of sequestration of ectopic tissue during embryologic development. A similar but distinctly different lesion is an epidermal cecal cyst. Pan, Rogers and Klass,4 in 1961, reported the first case of an epidermal cyst of the cecum and since that time two further cases have been reported.5'6 All these cysts were composed of stratified
.tIe I-Cases of epldermoldan4denpojd cysts of the cecunt Patients' age (yr), and sex 21, F 22, F 21,F 71,11 1,F 28, M right lower quadranL.
Case and reference nos. V 2'
Prwetttat1en. ObstnwtIQn RLQ mess RtQpafn RKtalbteedlng RLQmass RLQ mass
Type $4a. Denipkt 4etuW.o. 9
1372 CMA JOURNAL/DECEMBER 17, 1977/VOL. 117
In the hter*ure
Treent Local exc1.Ie NigtitI*mIcotect.nw. &*ca.vp
squamous epithelium without skin appendages. Epidermal cysts probably resuit from implantation of epidermal tissue during a surgical procedure, such as appendectomy. All reported cases of both types of lesion are summarized in Table I. J.F. MOSSEY, B Sc, MD
Department of surgery University of Alberta Edmonton, Alta.
LEN RIVERS, MD, FRCS[C] PETER PATrERSON, MD, ERc2P[CJ Departments of surgery and pathology Misericordia Hospital Edmonton, Alta.
References 1. GOWDY JM: Dermoid cyst of cecum. Gastroenterology 31: 447, 1956 2. KAY 5: Teratoid cyst of the cecum. Am I Dig Dis 16: 265, 1971 3. FINLAY-JONES LR, SINGH A: Dermoid cyst of the caecum. Med I Aust 2: 377, 1973 4. PAN A, ROGERS AG, KLAss AM: Epidermoid cyst of the cecum. Can Med Assoc 1 84:
1075, 1961 5. PEAR BL, WOLFF JN: Epidermal cyst of the
cecum. JAMA 207: 1516, 1969
6. CANDREVIOTIs N: Epidermoid cyst of cecum. JAMA 192: 425, 1965
Management of hypothermia To the editor: In a recent communication (Can Med Assoc J 117: 16, 1977) Dr. V. Wood reported the resuscitation of a patient with profound hypothermia (rectal temperature, 21 0C) and stated that only one other patient with accidental hypothermia has been reported to have survived a lower body temperature.' In fact, the lowest recorded core temperature of a survivor of hypothermia was 18 0C in an inebriated young woman as reported by Laufman.' Although mortality in hypothermia has been linked closely with underlying or associated disease states,3'4 the method of rewarming may also be a determinant.' Despite the lack of unanimity of opinion regarding indications for core rewarming, many authorities now advocate this mechanism for patients whose temperature is below 320C. In addition to the methods available for core rewarming mentioned by Sereda,6 including peritoneal dialysis, partial cardiopulmonary bypass and inhalation of heated oxygen, treatment with colonic infusions of warmed water was discussed in a recent report documenting the resuscitation of three patients with profound hypothermia (lowest temperature, 21.1 0C).7 As outlined by Dr. Wood, physiologic consequences of external rewarming make core rewarming techniques attractive, since many of these methods of reversing hypothermia can be rapidly instituted and require equipment available in most hospitals. Active external rewarming by water immersion, as advocated by Hunt,8 may interfere with adequate monitoring of the pa-