The mitochondrial myopathies give rise to a diverse group of clinical syndromes, variably involving skeletal muscle and the central nervous system, with onset in childhood or adult life. In vitro studies of mitochondrial metabolism have identified a variety of functional defects of the respiratory chain, predominantly affecting complex I or complex III in adults, and complex IV in children. The increased incidence of maternal, as opposed to paternal, transmission in familial mitochondrial myopathy has led to the suggestion that these disorders may be caused by mutations of mitochondrial (mt) DNA. This hypothesis is derived from observations that mtDNA encodes subunits of the respiratory chain proteins and is exclusively maternally transmitted. Analysis of muscle mtDNA shows two populations, one normal and the other deleted by up to nearly half its length, in about 40% of cases of mitochondrial myopathy. Only a single normal length population of mtDNA is seen in blood from these patients, and in blood and muscle from control subjects. Patients with muscle mtDNA deletions reported to date have all presented with progressive external ophthalmoplegia, including some with the Kearns-Sayre syndrome. They rarely have affected relatives. Deletions are not detected in cases of proximal myopathy alone, or those with adult onset syndromes predominantly affecting the central nervous system. There is no clear correlation between the deleted coding regions and the biochemical defects; even patients with seemingly identical muscle mtDNA deletions may be clinically and biochemically heterogeneous.