US 3040742 A
Description (OCR text may contain errors)
June 26, 1962 F. J. ElcHr-:LMAN
INHALATION THERAPY APPARATUS Filed Jan. l5, 1958 3 Sheets-Sheet 1 EP. BoYNToN N M EssER June 26, 1962 F. J. ElcHl-:LMAN
INHALATION THERAPY APPARATUS 5 Sheets-Sheet 2 Filed Jan. l5, 1958 EP. BoYNToN N. MTEss-ER June 26, 1962 F. J, EICHELMA'N INHALATION THERAPY APPARATUS 5 Sheets-Sheet 5 Filed Jan. l5, 1958 EP. BoYNToN N IVI EssER 3,040,742 Patented .lune 26, 1962 fire 3,040,742 INHALATIGN THERAPY APPARATUS Francis J. Eichelman, Brookfield, Ill., assigner to Chemetron Corporation, Chicago, Ill., a corporation of Delaware Filed `lan. 15, 1958, Ser. No. 709,031 9 Claims. (Cl. 12S-191) This invention relates in general to improvements in apparatus lfor the administration of gaseous fluids to achieve a therapeutic effect. More particularly, it relates to improvements in combined oxygen tent-nebulizer type apparatus permitting administration of inhalation therapy under optimum conditions of humidity and temperature.
Heretofore, the ready and selective regulation of humidity and temperature conditions of the special atmosphere confined in a canopy associated with an oxygen tent of the ice cooled or the iceless type while still maintaining desired gaseous fluid concentration within the canopy, has been difficult, if not impossible. The conventional humidifier and cooling apparatus is generally contained within the canopy itself and is capable of adjustment only after the canopy has been partially or completely removed. Obviously such action results in the escape of the special atmosphere within the canopy prolonging the period during which a patient must undergo inhalation thereapy, and adding to his discomfort.
Applicant has overcome these disadvantages by providing an improved high volume selectively controllable nebulizer in combination with an oxygen tent provided with means for selectively regulating the recirculation of gaseous fluids whereby in a single unit external of the associated canopy, ready, efiiecient and positive regulation of temperature and liquid entrainment or humidification operations are achieved.
It is -accordingly the principal object of this invention to provide in combination improved apparatus of the oxygen tent-nebulizer type for maintaining simply, selectively, and efficiently, optimum humidity and temperature control of canopy atmospheric conditions.
Another object of this invention is to provide a highly efficient and easily regulated high volume nebulizer in combination with an oxygen tent of either the iceless or ice cooled variety whereby liquid entrainment or humidifying operations may be selectively controlled.
It is a further object in conjunction with the foregoing objects to provide an oxygen tent with means capable of efficiently and positively controlling recirculation and relhumidifica-tion of the atmosphere of the tent canopy to achieve optimum humidity and temperature conditions within the canopy without affecting gaseous uid concentration therein or causing the patient any discomfort.
These objects and additional advantages of applicants invention will become more readily apparent as the following description proceeds taken in conjunction with the accompanying drawings therein:
FIG. l is a side elevation of the tent apparatus in cornbination with the high volume nebulizer and associated apparatus for suspending a tent canopy;
FIG. 2 is a cross sectional View on line 2-2 of FIG. 1;
FIG. 3 is an enlarged View partly in section of the valve assembly illustrated in FIG. 2;
FIG. 4 is a top plan View of the tent combination with the high volume selectively con-trollable nebulizer and further illustrating the manner in which the suspension means `for suspending the canopy is adjustably associated with the tent itself.
FIGS. 5 and 6 `are cross sectional views taken on line 3-3 of FIG. 4 illustrating the recirculation valve assembly in open and closed position, respectively.
FIG. 7 is a partial cross sectional view taken on line 4 4 of FIG. 4 illustrating the construction of the high volume selectively controllable nebulizer per se.
FIG. 8 is an enlarged cross sectional View of the selectively controllable valve mechanism of 4the nebulizer illustrated in FIG. 7.
FIG. 9 is a cross sectional View on line 9--9 of FIG. 8.
Referring now in par-ticular to FIG. l of the drawings, numeral :15 designates an oxygen tent provided |with double side and bottom walls 16, 17, 18 and 19, between which a suitable insulating material 20 such as corkl or the like is placed. There is also provided a closure member 21 having securing means such as toggle clasps 22 which cooperate with lugs 23 on the exterior of the side walls 16 and 17. Preferably on the same side walls 16 and 17 there are provided carrying handles 24.
The portion of the tent 15 that is to face the bed is provided With a pair of tubular -members 30 from the ends of which extend canopy supporting rods 3'1 and 32. Forwardly extending rods 32 preferably are provided with a slide ferrule and hinge arrangement 33 Iand telescoping extensions 34. A forward cross rod 35 insertable into bores in knurled knobs 36 at the outer ends of telescoping extensions 34 is provided to give greater rigidity to the canopy supporting structure. A canopy designated by numeral 25 is suspended from the supporting structure by suitable straps or rings 37.
A pair of hook-like members 38 adapted to be placed over the top rail of a conventional hospital bed (not shown) are connected to the rods 3'1 whereby the entire tent and canopy supporting arrangement may be suspended. To maintain the tent 15 in an upright position when thus suspended, a bumper member 39 which rests against the bed is secured to the lower portion of the tent 15.
The inside `of the tent =15 is provided with a vertical removable partition wall 40 which divides the interior of the tent into two compartments, one about half as large as the other. The larger compartment 41 holds a supply of ice on supporting drain plates 42 provided with legs 43. A drain valve y44 provides means for withdrawing efiiuent as required. Immediately above the plates 42 is a continuous coil 45 termina-ting at one end in a conduit 46 and a-t the other end in a conduit 47. These conduits extend under the partition Iwall 40 and into the smaller compartment 48 of the tent 15.
For a more detailed description of such elements as the tent and canopy supporting structures, and the features of the tent thus far discussed, reference may be had to my co-pending application Serial No. 533,113, filed September 8, 1955, for Combination Oxygen Tent and Nebulizer, of which this application is a continuation in part.
Referring again to the tent 15, the side wall 16 is provided with the main oxygen supply inlet 501 having a threaded fitting to which may be secured a conduit from any suitable gas supply (not shown). The oxygen inlet 50 terminates interior of the wall 16 in an elbow `51 (see FIG. 2) to which the conduit v46 preferably is secured by fitting 52. Conduit 47 preferably is provided at its terminus with a connector member 53 adapted to threadedly engage a tube 54 which in turn is engaged at 55 to a nebulizer apparatus 60.
In the preferred embodiment illustrated the nebulizer apparatus `comprises a block-like housing 611 preferably is secured to the outside .of wall 18 of the `tent chest 15 by a bracket and lbolts 62. In this position the nebulizer apparatus A60 is easily accessible for cleaning and for replenishing the liquid supply. lllhe blockdike housing 61 is preferably of a clear plastic material and is provided With a central bore '63 flaring outwardly in an inter- Y mediate section at 64, to a larger diameter bore `65 at an opposite end concentric with the bore 63. 'Dhe bore 63 is provided with a rearwardly extending tubular member 66 preferably formed of a substantially non-corrosive metal. 'IIhe member `66 provides an auxiliary housing for the nebulizer gas and liquid nozzles to be described later. Within the bore 65 are positioned a series of mesh screening members 67 the purpose of which will be described in conjunction with the operation of the nebulizer.
The forward or delivery end of housing 61 is completed by another block 68 which is centrally bored at 69 and then flared outwardly at 70. Together the flared walls 64 and 70 form a venturi chamber 71 central-ly and transversely of which the screening members 67 are located. From the forward end of the bore 69 there extends a tubular member 72, the purpose of which is to project through an opening (not shown) in canopy 25. The forward assembly l68 preferably is secured to the nebulizer main housing 61 by means of a plate 73 and screws 74 thus completing the nebulizer housing.
Beneath and suspended from the nebulizer housing 6.1 is a receptacle 80 for liquid 81 to be nebulized. The receptacle 80 preferably is made of a plastic material and is provided at its upper end with a peripheral groove 82 for engagement by one or more oppositelyV spaced inturned clamps 83, adjustably secured to the block 61 by a threaded hand wheel arrangement 84 (see FIG. l).
Extending from the tubular housing 66 within the block 61 and downwardly into the receptacle 80 is a liquid throttling valve assembly designated by numeral 85 (see FIG. 8). The valve assembly 85 comprises a liquid injector member 86 provided with a longitudinal bore 37 which at its upper end terminates in a liquid nozzle 88 having an` orifice 89. Injector member 86 is maintained in position with respect to block 61 by means of a bracket .l
90 in threaded engagement with member 86 and preferably having a tapered portion 91 which abuts a bushing 92 in block 6:1, and in cooperation with sealing member 94 and lock nut 95. The injector member '86 is further preferably provided with a hexagonal surface 96 facilitating its upward and downward threaded adjustment. The lower end 97 of injector member 86 is also externally threaded to receive an internally threaded valve shut off assembly 100 preferably provided with a knurled portion 101, the function of which will 'be explained later, and a ribbed surface 102 adapted to receive a tubular withdrawal conduit 103. A lock nut 104 is positioned on end 97 of injector member 86 to restrict upward movement of assembly 100 for reasons that will become apparent when the operation of the device is described. The ends of the valve shut off assembly 100 are counterbored to provide liquid chambers 105 and 106 which communicate with one another through a plurality of passages 107 provided in an intermediate section 108 of assembly 100. Section 108, in addition, is provided with a central recess 109 adapted to receive the reduced end 110 of a valve stem 111. The valve stem 111 of sufficiently lesser diameter extends into bore 87 of injector member 86 permitting flow of liquid through the annulus between stern 111 and bore 87 from communicating chamber 106 of the valve shut olf assembly 100. Valve stem 111 preferably terminates at its upper end in a tapered seating surface 112. Seating surface 112 of stem 111 may ibe urged Itoward or away from nozzle 88 by appropriae rotatable adjustment of the valve shut off assembly 100 by means of knurled portion 101. The lock nut 104 not only maintains valve assembly 100 in position after adjustment thereof Vis made, but also restricts upward movement of valve assembly 100 and therefore, stem 111, thus preventing damage yto its seating surface 1112 and that of liquid nozzle 88. 'Ilhe adjustment of the valve assembly 100 will be treated more fully in the description of the operation of the device.
Returning now to tubular lhousing 66 and bracket 90 in particular, one end of bracket 90 is provided with a guide opening through which a gas nozzle 115 extends, the latter being provided with a restricted oriice 116. The terminal end of the gas nozzle 115 is threadably engaged to connected member 55. At the forward end of bracket there is positioned a target or impingement surface 117, which is secured to bracket 90 by means of a leg 118. The preferably spherical target -member 117 is positioned within t-he venturi lchamber 71 formed by the flaring walls 64 and 70 in the housing assembly 61 and 68. The bracket 90 maintains the relative posi-tions of the gas nozzle 115, the liquid nozzle 8S, and the target member 117 in a preadjusted position adapted to secure maximum nebulization of liquid. This is best accomplished by forming and positioning the bracket 90 so that the gas nozzle 115 extends substantially axially into the tubular housing 66 to a position in which its orifice is closely adjacent the orifice 89 of the liquid nozzle `88. The orifice end of the liquid nozzle 88 is preferably tapered to-ward the orifice 89 which is preferably positioned in a plane slightly above the center of the oniiice 116 of the gas nozzle 115. In this manner, gas issuing from the vlgas nozzle will strike first the tapered end of the liquid nozzle 88 and be deflected upwardly adjacent the liquid orifice 89 and therefrom against the target 117, the center of which is substantially in line with the projected axis of the gas nozzle 115, ibut at a greater distance from the liquid nozzle orifice 89 than the latter is positioned from the gas nozzle orifice 116.
This neb-ulizer is adapted to -nebulize and deliver a high volume of liquid in minute particle sizes in the `range of 3 microns or less. To insure that particle sizes delivered through the delivery tube 72 Vinto the canopy 25 are substantially uniform, the screering 67 is provided so that luge-r moisture particles are deposited thereagainst .and drain through the tube 119 back into receptacle 80 and the liquid supply 81.
The nebulizer is completed with a transverse bore 120 forming an inspection port preferably in :the upper portion of the nebulizer main housing 61 and the tubular chamber 66 in the vicinity of the liquid and gas nozzles 88 and 115, and is provided with a suitable closure member 121. In this manner Ithe operating 4apparatus may be inspected by removal of the closure 121, and particularly if for any reason the liquid nozzle V88 becomes clogged it is readily accessible and may be cleaned by inserting a fine wire through the inspection port 120 into the liquid orifice 89.
It will ba noted that the rea-r of 'the housing 66 opens into the tent chamber 48. In the other or ice containing chamber 41 of the tent 15 there is another port 125, forwardly of which extends la tube 126 which is suitably secured to wall 18 of tent 15. Within tube 126 there is positioned a recirculation control valve arrangement such as butterfly valve assembly 130 (see FIGS. 3, 4, 5, and 6). Valve :assembly 130 maintained in adjustable engagement with respect to xtube 126 preferably by means of lock pins 131 land 132, one end of each of which is passed through holes in the wall of tube 126 and preferably press fitted into knurled adjusting knobs 133 and 134, and the other ends of which Iare similarly engaged to a post member 135. Sealing members 136 and 137 are provided between knobs 133 and 134 and the wall of tube 126 to pr.- vent loss of gaseous flu-ids being recirculated through tube 126. To complete the valve assembly 130, `a disc 133, provided with stop means Asuch as screw 139 and nut 140, is preferably brazed to the post member (see FIGS. 5 and 6). Stop means 139 and 140 are positioned nea-r the periphery of disc 138 `and prevent movement of the disc 138 through van angle greater than 90. This is accomplished by permitting a portion of the nut 140 to extend beyond the edge of disc 13S. Thus in the closed position of the valve Aassembly 130, the protruding edge of nut will make contact with the inner wall of tube 126 preventing further movement (see FIG. 6) and in the open position the end of screw 139 will similarly restrict movement of disc 138 (see FIG. 5). The tube 126 is placed in communication with canopy 25 4by means of an extension tube 141 which is preferably slip tted over tube 126 `and inserted through an opening (not shown) in canopy 25.
It will be noted that the venturi chamber 71 of the nebulizer 60 creates Ian area of `low pressure rearward thereof within the housing 76 so that moisture laden gas entering the canopy 25 through the delivery tube 72 is recirculated from the canopy through the retinn tube 141, past valve assembly 130 in tube 126, and into the larger ice chamber 41 of the tent 15, in which it will be further cooled. flt should be noted that the gasis initially cooled through coil 45 ias described in co-pending lapplication Serial No. 533,113 to which reference was previously directed. The amount of gas being recirculated into charnber 41 can be controlled by adjustment of disc 13S by means of control knob 133, the top of which is appropriately marked to indicate the direction of turning to the open or closed position of the valve arrangement 130. Through such ladjustment it is possible to achieve readily and eiiciently desired temperature conditions within the canopy 25. Obviously, successful land continuous operation of the device requires that some gas be recirculated at all times and therefore, even in the closed position oircumferential passage of gas about disc 133 occurs. As the recirculated atmosphere is cooled by the ice, a certain amount of moisture 'and dissolved impurities will be condensed out yand washed by the melting ice to the bottom of the tent where these iand melted ice are Withdrawn from time to time through the drain Valve 44. The thus cooled atmosphere is then passed below the partition 46 through chamber 48 into the housing 66 land again through the nebulizer 6G by way of the venturi chamber 71. Nebulization, and therefore, the amount of humidiiication of the canopy atmosphere can be controlled by adjusting valve stem 111 upwardly or downwardly with respect to liquid nozzle 88 lby means of the knurled portion 101 of valve assembly 100. In this manner -a constant recirculation and optimum recocling and humidication of the canopy atmosphere is achieved to produce the desired therapeutic effect.
The tent 15 is, in addition, provided with another oxygen inlet 142, having suitable closure means such as a check valve (not shown) and provided with a barbed end (see FIG. l) to which -a supply conduit I(not shown) may be attached. This .added inlet Lin cooperation with the venturi yarrangement of the nebulizer 60 enables oxygen to be admitted directly into the tent and through the nebulizer venturi '71 into the canopy 25 without increasing the nebulizing rate of the nebulizer 60. In this manner added oxygen may be introduced for such purposes las flushing the tent Iand canopy, varying the volume of recirculated canopy atmosphere, and, in cooperation with recirculation valve `assembly 130, affecting temperature control and maintenance within the canopy 25.
The cooperative action of the preferred embodiment of tent and nebulizer described -above enables an operator to achieve either maximum or decreased cooling with full nebulization, or -maximum or decreased cooling with less nebulization. In achieving maximum cooling with full nebulization, valve shut off assembly 100 is turned clockwise at least one complete turn by means of knurled portion 101 to move valve stem 111 away from liquid nozzle 8S. Valve yassembly 130 is then adjusted to the completely open position illustrated in FIG. 5. In this manner maximum liquid is entrained in the incoming gas and maximum moisture laden gas is being recirculated through the canopy.
To achieve decreased cooling with full nebulization it is necessary to adjust recirculation valve 'assembly 130 to some intermediate or a closed position (see FIG. 6). Valve stem 111 is then moved away from liquid nozzle 88 as above. To achieve less nebulization with maximum cooling, it is only necessary to move valve stem 111 into proximity to liquid nozzle S8 by adjustment of valve assembly 10i) in -a direction opposite to that for achieving full nehulization. Decreased or increased nebulization can be ascertained by the degree of fogging visible at delivery tube 72.
It will be readily appreciated that by combining applicants highly eiiicient and easily operable high volume nebulizer with oxygen tent apparatus, numerous advantages 'are achieved. Proper adjustment of either or both .the valve stem 111 `of the nebulizer 60 and the recirculation valve assembly 130 in tube 126 of the tent 15 enables an operator to obtain optimum temperature and humidity conditions within the canopy. This has obvious advantages in that it makes possible the maintenance of high oxygen concentrations within the canopy `both before and after adjustment of humidity and temperature controlling mechanisms. Such an Iarrangement clearly contributes to the therapeutic effect sought to be yachieved by the administration of such moisture laden oxygen and also materially adds to the well being of the patient undergoing such treatment.
In addition to the operations of applicants apparatus already discussed, it should be pointed out that complete closure of valve assembly permits administration alone of oxygen, or mixtures of oxygen and other gases such as, for example, helium, to achieve a specic therapeutic result in an unhumidified atmosphere. Such application is important in the treatment of certain heart and respiratory disorders.
Although applicant has disclosed a preferred embodiment of a combination high volume nebulizer and oxygen tent, it will be apparent that other apparatus may be substituted in applicants combination and still function in substantially the same manner. It will be further apparent therefore that certain modifications will be suggested to those skilled in the art and all such modications as come within the spirit of this invention are intended to be included within its scope as defined 4by the appended claims.
l. In an oxygen tent apparatus for controlled inhalation therapy, the combination comprising a canopy, a heat insulated cooling chamber external of said canopy, a tubular coil within said cooling chamber through which an oxygen-containing gas is passed, said tubular coil having an inlet end and an outlet end a liquid nebulizer at the outlet endrof said tubular coil and external of but communicating with said canopy, and means in communica,- tion with said nebulizer for selectively regulating the amount of liquid nebulized by said cooled gas passing through said nebulizer.
r2. In an oxygen tent apparatus for controlled inhalation therapy, the combination comprising a canopy, Ia heat insulated cooling chamber external of said canopy, passage means intercommunicating the canopy and the cooling chamber, a tubular coil within said cooling chamber through which an oxygen-containing gas is passed, a liquid nebulizer at the outlet end of said tubular coil adapted and arranged to pass the gaseous stream through said passage means to establish an atmosphere in said canopy, said nebulizer having a venturi chamber for causing recirculation of the established atmosphere in said canopy through said passage means, cooling chamber and said nebulizer, and means for selectively controlling the recirculation of the atmosphere in said' canopy through said cooling chamber and said nebulizer.
3. In an oxygen tent apparatus for `controlled inhalation therapy, the combination comprising a canopy, a heat insulated cooling chamber external of said canopy, passage means intercommunicating the canopy and cooling chamber, a tubular coil within said cooling chamber through which an oxygen-containing gas is passed, a liquid nebulizer at the outlet end of said tubular coil adapted and arranged to pass the gaseous stream through said passage means to establish an atmosphere in said canopy, means in communication with said nebulizer for selectively regulating the amount of liquid nebulizer, a venturi chamber in said nebulizer for causing recirculation of the established atmosphere in said canopy through said passage 7 means, cooling chamber and said nebulizer, and means for selectively controlling recirculation of the atmosphere in said canopy through said cooling chamber and said nebulizer.
4. In an oxygen tent apparatus for controlled inhalation therapy, the combination comprising a canopy, a heat insulated cooling chamber external of said canopy, a plurality of passage means intercommunicating the canopy and cooling chamber, a tubular coil within said cooling chamber through which an oxygen-containing gas is passed, a liquid nebulizer at the outlet end of said tubular coil adapted and arranged to pass the gaseous stream through at least one of said passage means to establish an atmosphere in said canopy, said nebulizer having a venturi chamber for causing recirculation of the established atmosphere in said canopy through another of said passage means, said cooling chamber and said nebulizer, and a valve positioned in said other passage means intercommunicating said canopy and said cooling chamber for selectively controlling the recirculation of the atmosphere in said canopy through said cooling chamber and said nebulizer.
5. An oxygen tent apparatus as claimed in claim 4, in which said valve comprises a rotatably adjustable disc and stop means for limiting rotation of said disc.
6. A nebulizer -for entraining particles of finely divided liquid in a gaseous stream, comprising a main housing provided with a central longitudinal bore, said bore being ared at an intermediate portion to provide a venturi chamber, a gas nozzle, a liquid nozzle, means including an adjustable valve for controllably conveying liquid from a source to Vsaid liquid nozzle, an impacting surface spaced apart and positioned substantially at the inlet side of the venturi chamber, and metal mesh screening mate- `rial positioned centrally Within and transversely of the ,-venturi chamber, said apparatus adapted to pass a stream of gas under pressure from the gas nozzle to adjacent the liquid nozzle to draw a selectively controllable quantity of liquid from said source into the stream and impact it into particles against lthe impacting surface and thereafter to deposit only the large liquid particles on the mesh screening so that a substantially uniform moisture laden cloud issues from the outlet end of the said venturi chamber.
7. A nebulizer as claimed in claim 6, in which the adjustable valve is provided intermediate said liquid nozzle and said liquid source whereby the amount of liquid drawn through said gas nozzle may be selectively controlled.
8. vIn an oxygen tent apparatus for controlled inhalation therapy, fthe combination comprising a canopy, a heat insulated cooling chamber external of said canopy, a plurality of passage means intercommunicating the canopy and the cooling chamber, a :tubular coil within said cooling chamber through which an oxygen-containing gas is passed, a liquid nebulizer at the outlet end of said tubular coil for passing the gaseous stream through at least one of said passage means to establish an atmosphere in said canopy, a liquid injector member terminating in a liquid nozzle positioned in said nebulizer, a valve assembly including a valve stem in adjustable engagement with said injector member adapted to be urged toward or away from said liquid nozzle for selectively regulating the amount of liquid nebulized, a venturi chamber in said nebulizer for causing recirculation of the established atmosphere in said canopy through another of said passage means, said cooling chamber and said nebulizer, and an adjustable butterily valve positioned in said other passage means, said butterfly Valve being provided with at least one adjusting knob and Stop means for selectively controlling recirculation of the atmosphere in said canopy through said cooling chamber and said nebulizer.
9. In an oxygen tent apparatus for controlled inhalation therapy, the combination comprising a canopy, a heat insulated cooling chamber external of said canopy, passage means intercommunicating the canopy and the cooling chamber, a tubular coil within said cooling chamber through which an oxygen-containing gas is passed, the inlet end of said coil communicating with a source of said gas, a gas nozzle in communication with the outlet end of said (tubular coil, a liquid nebulizer in communication with said gas nozzle, said nebulizer being adapted and arranged fto pass the gaseous stream through said passage means to establish an atmosphere in said canopy, means in communication with said nebulizer for selectively regulating the amount of liquid nebulized, another inlet in Comunication with asid cooling chamber for entry of substantially uncooled oxygen-containing gas from a source thereof, a venturi chamber in said nebulizer for causing recirculation of the established atmosphere in said canopy through said passage means, said cooling chamber and said nebulizer, means for selectively controlling recirculation of the atmosphere in said canopy through said passage means, said cooling chamber and said nebulizer whereby in cooperation with said rst mentioned means and said other inlet for said cooling chamber conditions of temperature and humidification of the atmosphere in said canopy may be varied.
References Cited in the le of this patent UNITED STATES PATENTS 2,785,768 Gauchard Mar. 19, 1957 y2,852,022 Netteland Set. 16, 1958 2,852,022 Netteland Sept. 16, 1958 2,920,622 Steel Jan. 12, 1960 FOREIGN PATENTS 856,788 France Apr. 1, 1940 405,564 Italy Aug. 20, 1943 973,081 France Sept. 6, 1950 1,047,652 France July 29, 1953