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The dexamethasone (DXM) test has been widely used for diagnosing Cushing's disease (CD). The purpose of this paper is to review its diagnostic merit based on calculation of data extracted from earlier publications. Studies presenting individual values for patients with CD and normal subjects were identified through PubMed searches and references in pertinent studies. Calculation of the retrieved data demonstrated huge variation in the relative suppressibility, negative suppression being common. Furthermore, in almost each study retrieved, the pre and post DXM values were closely correlated. Finally, the generally accepted view that DXM causes less suppression in Cushing's disease than in euadrenal controls appears unfounded. A central issue in the definition of so-called "pseudo-Cushing's states" is failure to suppress cortisol secretion with DXM. From analysis of the literature it appears quite possible that this does not reflect a specific endocrine deficit, but a physiological "stress" reaction. The above issues question the diagnostic value of the test, in particular in clinically and biochemically borderline cases.

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A brief overview of the most important steps leading to our present knowledge of hypercorticism is given. The adrenals were described in 1563 and the pituitary had been known since Antiquity. Until Addison's description of adrenal insufficiency in 1855 virtually nothing was known of their function. Cushing in 1912 described his famous patient with hypercorticism but assumed it to be a polyglandular disorder. For almost 40 years the etiology was disputed, though Bauer early had postulated that hypercorticism ultimately reflected adrenal hyperfunction, either primarily or secondarily. Though Krause, Schloffer, Cushing, Hirsch and others early in the 20th century had introduced pituitary surgery, it was not until 1933 that the first patient with Cushing's disease had neurosurgery performed. This therapy did not gain wide acceptance until Gidot & Thibaut and Hardy pioneered transsphenoidal surgery. Adrenal surgery was for many years the treatment of hypercorticism but prior to the availability of glucocorticosteroids substitution an extremely perilous undertaking.

567tends to be slowest in the active adult years. If infant deaths are common, this difference in mean age is likely to be accentuated.The balance of sexes of an exhumed population is statistically more likely to predominate in male skeletal remains, because of the relatively greater robustness of the male skeleton favouring preservation.It is recommended that any subsequent investigation of a similar nature should be conducted on remains exhumed from a non-acid medium. AcknowledgementWe wish to thank Reverend R. Brown, the Rector of St. Michael's Parish Church, for granting access to the parish registry, and him and his verger for supplying much of the background historical data relating to burial traditions. We are indebted to Dr. B. Davies, Medical Officer of Health for Ashton-under-Lyne, for his help, and to Mr. W. E. Aikin, the superintendent registrar for permission to view the town's burial records. Special thanks are due to the Medical Research Council and to the United Manchester Hospitals for their financial aid, without which the project could not have been made. Finally, we wish to thank Professor J. L. Hardwick and other members of the team for their assistance in collecting the basic records from which the data were drawn. Further ReadingAikin, J., in A Description of the Country from Thirty to Forty miles round Manchester,