Clinical Description. “Mr. Colles…from about the year 1834 was the subject of a chronic bronchitis, with occasional exacerbation of the disease in the acute form …In 1840…Mr. Colles had retired to bed, feeling as well as usual, but during the night was seized with a paroxysm of cardiac asthma…he remained in a state of orthopnea during the night. In the morning the pulse was rapid, irregular and unequal… the legs remained unusually edematous…So irregular and rapid was the action of the heart, that the analysis of the sounds was a matter of great difficulty …Mr. Colles was recommended to try the effect of change of air and travel… He proceeded to Switzerland, where his health was so greatly improved…after his return to Dublin, his old attacks returned. I saw him and for the first time observed that the liver was permanently enlarged … he continued to suffer, from time to time, from paroxysms of dyspnea, which were generally preceded by a diminution in the secretion of the kidneys. During these attacks… the irregularity of the heart and the precordial distress increased, until orthopnea was established. The kidneys acted scantly…on each attack the tumefaction of the liver increased with great rapidity, but this condition as rapidly subsided with the improvement in symptoms. No relief was ever obtained until the action of the kidneys was established; but it was found that this could only be effected by the use of mercury… In this condition of intervals of comparatively good health, while the attack came on once in about every five weeks … another bad attack supervened…but it yielded to the usual treatment. But this was the last time that the system responded to medicine…The anasarca increased, and the occurrence of a congestion of both lungs…was the immediate forerunner of death.” Autopsy Findings. “The heart was much larger than natural;…the left ventricle…its cavity was remarkably large… the auriculo-ventricular openings were natural; and the same may be said of the aortic orifice…” Conclusion. “…In a clinical point of view these cases form one of a group of diseases which may be classed as examples of weakness of the heart. For although they differ in the special signs and symptoms, and, above all in their history and accompanying circumstances, yet they agree in exhibiting a diminished force, especially of the ventricles.”1 Commentary. William Stokes' description of Dr. Colles' disease portrays several important clinical observations about the syndrome of heart failure: 1) the likelihood of nonischemic dilated cardiomyopathy as the etiology of Colles' disease, since the patient did not experience chest pain; 2) the association of orthopnea and rapid pulse (atrial fibrillation?); 3) the syndrome of refractory congestive heart failure as the mode of death; 4) the cyclic nature of frequent decompensations; 5) the relationship of clinical worsening in conjunction with reduced urine output, as well as the importance of re-establishing urinary flow in order to decrease dyspnea; 6) the use of mercury as a diuretic; 7) the autopsy findings of an enlarged heart with normal valvular structure (dilated cardiomyopathy?); and 8) the decrease in heart function as a mechanism of the disease. Astute clinical observation, a detailed history, clinicopathologic correlation, and a clear prescription regimen are the legacy of the Irish School of Medicine, and this contribution to the understanding of heart failure is further evidence of this legacy.