Thanks to the request by the Annals editor to comment on the evolution of medical journals during the past quarter century, I had the pleasure of scanning the 1977 issues of several major journals. In those ancient and primordial days of medical science, case reports, observational studies of a few dozen patients, and physiologic experiments ruled the journals' pages. Few of us would have predicted then that molecular medicine, enormous controlled trials, and meta-analyses of dozens of clinical trials would largely replace them in the years to come. Needless to say, advances in science in the intervening years have revolutionized our diagnostic, prognostic, and therapeutic capabilities, yet many vexing issues documented in these journals in 1977, such as cost containment, medical work force, the quality of care, the ethics of clinical trials, the value of mammography, and the physician as patient advocate, still grace the pages of today's journals. Some of these issues are more vexing than ever. There is little doubt that progress, though stunning in scientific achievements, has been spotty and uneven in health care ethics, financing, and delivery.