another factor which contributed to the high death tolls was the status of medical care at the beginning of the civil war. in 1861, medical knowledge, diagnostic procedures, equipment, and treatment protocols were very crude by modern standards. because doctors were often unaware of what caused the diseases they were encountering, and because medical hygiene practices were poor compared with those practiced today, physicians often could do very little to treat their patients; in many cases, they even hastened soldiers' deaths by failing to wash their hands and instruments before moving from one patient to the next - simple protocols which did not begin to take hold until later in the war through the pioneering military medical management efforts of william a. hammond and jonathan letterman. as a result, at times, a physician's treatment of wounds, infections and diseases did more harm than good.