Westphal in 1915 expressed the opinion that there were neither war psychoses nor neuroses and that these conditions did not differ in any way from those described in times of peace. MacCurdy,[101] who made an elaborate study of war neuroses in 1917, described them as being either anxiety conditions or simple conversion hysterias. He looked upon fatigue as being a very important factor in the development of a neurosis, with either a physical accident or a mental shock as the precipitating cause. He defines war neuroses as "Those functional nervous conditions arising in soldiers which are immediately determined by modern warfare and have a symptomatology whose content is directly related to war." MacCurdy found that concussion could be considered as a possible factor in less than one-fourth of the cases he observed. He refers to minute cerebral and retinal hemorrhages with blood in the cerebrospinal fluid as an evidence that concussion is a cause in some cases. Curschmann, Meyers, Buzzard, Farrar and various others have noticed that the gross hysterical manifestations were extremely rare in officers. After an extended discussion of the etiology of the war neuroses, Farrar in 1918 expressed as one of his conclusions the opinion that "The drift of opinion is unmistakable towards the psychogenic basis of war neuroses of all types, including shell shock. Even in the initial unconsciousness or twilight state of some duration there is evidence that the psychogenic element may have as great if not a greater rôle than the item of mechanical shock, although this is also important." Hartung[102] in 1918 reported a study of 780 cases of war neuroses treated by him at Thal. About ninety-eight per cent were cured by psychic and mechanical treatments. One hundred and sixty-two cases showed hysterical paralysis, the lower limbs being affected twice as often as the upper. Tremors of the head or upper limbs were present in twenty-eight per cent, hysterical convulsions in eight per cent, speech disturbances in five per cent, hearing disorders in one per cent, cardiac and respiratory symptoms in 1.5 per cent, neuroses of the digestive system in 1.5 per cent, and bladder disturbances in 1.5 per cent of the cases. Neurasthenia "in the strictest sense of the word" was present in twenty per cent. Hurst[103] and others have spoken of endocrine disturbances in war neuroses. He includes hyperadrenalism and hyperthyroidism due to an over-stimulation of the sympathetic nervous system, resulting from such emotions as anger and fear. Rapid pulse, enlargement of the heart, and high blood pressure were common symptoms. The patients in some cases showed conditions strongly suggesting Graves' disease. In addition to the circulatory disturbances there was paroxysmal sweating, the eyes were slightly prominent, sometimes with von Graefe's sign, and pilomotor reflexes were present.