At 5 a.m. on May 4th, 87-year-old Alfred Mann woke up with a strange object in his mouth. Reaching for his handkerchief, he spat out a half-inch metal shard -- shrapnel from a battle injury he sustained 65 years ago.
"It was a surprise," said Mann of Sheldon, Birmingham, in the U.K.
Mann, who served as a nurse with the Royal Army Medical Corps during World War II, was injured by an exploding land mine in Monte Cassino, Italy, at age 19. The blast left him with injuries to his face, shoulder and leg, as well as hearing loss.
Mann was treated at a hospital in Naples, but no one discovered the piece of shrapnel lodged somewhere in his jaw. Even after he healed, Mann was limited to eating soft foods and he had difficulty speaking. During the years, doctors attributed the pain and bleeding in his mouth to ulcers, advising him to see dentists.
Although Mann suffered significant medical problems, it is not uncommon for doctors or patients to overlook a piece of metal lodged somewhere in the body -- accidentally or on purpose.
"If [the shrapnel] is not near anything sensitive, they may not even notice it," said Dr. Gerard Rebagliati, assistant professor of Emergency Medicine at Oregon Health and Science University in Portland.
The greatest dangers with shrapnel injuries are if they are lodged in or near vital organs or if they migrate to areas where they are not supposed to be and cause damage.
But if a piece of shrapnel has little potential for damage, doctors will often leave the fragment in the body rather than perform risky surgery, which will further damage body tissues, to remove it, even if they have a general idea where the shrapnel might be.
"The reason foreign bodies get left behind is because with war injuries, even more than with civilian-type gunshot wounds, there can be literally thousands of fragments deep within the muscles," said Dr. Jay Doucet, director of the Surgical Intensive Care Unit at the University of California, San Diego. "If you do so much cutting and sectioning, you end up causing worse problems then the fragments themselves cause."
Unless they are close to the skin's surface, bits of shrapnel will move and shift with the body's tissues, making them even more difficult to find and remove.
And particularly in the heat of a war, when surgery may serve as damage control rather than a thorough operation, Doucet said if bits of shrapnel are not causing infection, are not disturbing body functions, as they would if they were lodged in a joint, for example, are not causing pain and do not seem easy to remove, then they can be left behind.
But the body has ways of dealing with foreign objects that are left behind. In some cases, bits of shrapnel will work their way to the skin's surface and be expelled, although Rebagliati said the exact mechanism for this is unknown.
Alternatively, the body may create a protective capsule around the foreign body so that it will not migrate to other locations or spread infection, although shrapnel fragments may already be sterilized from the heat of the blast.
"You can just leave it there," Rebagliati said. "The body tends to react to objects like that by walling it off with inflammation."
Once scar tissue forms around the shrapnel, it may be easier to remove with surgery.
Rebagliati said the piece of shrapnel that came out of Mann's mouth may have been embedded in the soft tissue around his jaw, close enough to either the nerves or muscles involved in mouth movements, which may have been the source of his problems eating and speaking.
"It was probably all mechanical," Rebagliati said. "Like having a ball bearing stuck in a doorway."
Mann still has several bits of shrapnel left in his hands that have never come out or been removed. But now that the shrapnel from his jaw is gone, Mann is better able to speak and eat and his jaw pain is gone.
"I've got no pain at all," Mann said. "[My wife] is quite pleased with it."
"It was a shock, yes," said Mann's wife, Constance. "But he just had this stuff come away from him and he's alright now."