The first evidence of widespread dissatisfaction with the way in which sick people were provided with nursing care dates from the 1830s. It is important to recognize, however, that this evidence does not come from either nurses or patients. Both were likely to belong to classes of the population who leave few written records of their own, even if they were not actually illiterate. The complaints come from two particular sources. One was a group of physicians and surgeons who were introducing new ways of practising medicine that were radically changing the whole nature of hospitals. The other was a circle of well-connected philanthropists whose criticisms expressed both the reforming spirit of evangelical Christianity and a growing concern about the fragility of social order under the stresses of industrialization and urbanization. These two factions had rather different visions for the future of nursing but their combined influence transformed the standards expected from care providers in the home or in institutions.
To understand the changing environment in which nursing care was being given, we need to retrace our steps a little to consider how medical practice had been developing since the end of the eighteenth century among the elite practitioners who were later to join into the modern profession of medicine. Before this time, their work had been only loosely linked to hospitals. These might, as in Edinburgh and Leiden, be places where a medical education happened to be given but they were not centres of research and expertise in the way they are today.
Until the beginning of the nineteenth century, the development of medical knowledge took place in two ways: the elaboration of nosologies, or systems for classifying symptoms, and speculation