Arch Intern Med (Chic). 1923;31(1):85-95. doi:10.1001/archinte.1923.00110130088008.
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Numerous theories have been advanced from time to time to account for orthopnea, but there has been surprisingly little discussion of the subject. Hewlett1 sums it up as follows:

It is well known that patients suffering from dyspnea, and particularly those suffering from cardiac dyspnea, cannot breathe as comfortably when lying down as when sitting up. The dyspnea which necessitates an upright posture is spoken of as orthopnea. The exact cause of orthopnea is not definitely understood. According to the views of earlier authors, the sitting posture allows better fixation of the shoulders, and this favors the use of the accessory muscles of inspiration, but Hofbauer showed that these patients experienced their chief difficulty in expiration rather than inspiration. The upright posture is a more favorable one for expiration, because the anterior abdominal wall is pushed out by the lower position of the abdominal viscera, and when it contracts during


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