Because of increasing anemia, triamcinolone, 8 mg. daily, was started on Feb. 23, 1958, and was continued until july, 1958. In september, 1958, the patient developed generalized weakness and fatigue which was concurrent with exacerbation of his anemia; the hemoglobin was 10.6 gm.. In an attempt to reverse the downhill trend by stimulating the bone marrow and controlling any hemolytic component, triamcinolone, 16 mg. daily, was begun on Sept. 26, 1958, and continued until Feb. 18, 1959. At first the patient felt stronger, and the hemoglobin rose to 13.8 gm., but on Oct. 20, 1958, he complained of ``caving in'' in his knees. By Nov. 8, 1958, weakness, specifically involving the pelvic and thigh musculature, was pronounced, and a common complaint was ``difficulty in stepping up on to curbs.'' Prednisone, 30 mg. daily, was substituted for triamcinolone from Nov. 22 until Dec. 1, 1958, without any improvement in the weakness. Serum potassium at this time was 3.8 mEq. per liter, and the hemoglobin was 13.9 gm. By Dec. 1, 1958, the weakness in the pelvic and quadriceps muscle groups was appreciably worse, and it became difficult for the patient to rise unaided from a sitting or reclining position. Triamcinolone, 16 mg. daily, was resumed and maintained until Feb. 18, 1959. Chlorothiazide was omitted for a 2 -- week period, but there was no change in the muscle weakness.

At this time a detailed neuromuscular examination revealed diffuse muscle atrophy that was moderate in the hands and feet, but more marked in the shoulders, hips, and pelvic girdle, with hypoactive deep tendon reflexes. No fasciculations or sensory defects were found. Electromyography revealed no evidence of lower motor neuron disease. Thyroid function tests yielded normal results. The protein bound iodine was 6.6 | mg.%, and the radioactive iodine uptake over the thyroid gland was 46% in 24 hours, with a conversion ratio of 12%. A Schilling test demonstrated normal absorption of vitamin ** f. In February, 1959, during the second admission to The New York Hospital, a biopsy specimen of the left gastrocnemius showed striking increase in the sarcolemmal sheath nuclei and shrunken muscle fibers in several sections. Serial serum potassium levels remained normal; the serum glutamic oxaloacetic transaminase was 10 units per ml. per min.. The clinical impression at this time was either muscular dystrophy or polymyositis.