Inside a massive cave in Borneo, called Liang Tebo, archaeologists have discovered a striking 31,000-year-old burial of a young adult with a missing lower left leg. What was particularly perplexing was that the limb wasn’t chewed off by animals or severed by other humans during a conflict. Instead, it seems to be the mark of surgery – an intentional medical act, which in this case involves an amputation. And if that is the case, it could mean surgeries could be more than 25,000 years older than previously thought. Previously, archaeologists found figurative rock art at least 40,000 years old in the area. 

“The proximity to this early art, and East Borneo’s strategic location on the eastern edges of Ice-Age Sunda (Eurasia), motivated us to search this important and understudied area of the tropics. The archaeological record we have discovered provides a compelling case that the society living here 31,000 years ago, regularly practiced figurative and complex art [and] had mastered the complexities of advanced medical practice, enabling a child to survive the surgical removal of their lower left leg, and live into adulthood as an amputee. There is little doubt that this thriving community cared for this valued individual, commemorating their life in what is now the oldest known human burial from South East Asia, placing vibrant red ochre pieces within their grave,” Tim Maloney, a research fellow at the Griffith University in Australia, told ZME Science.

Amputations: a hit or miss for most of medical history

Nowadays we take healthcare for granted, but it was less than a hundred years ago that people died by the millions from common infections that are now treated with antibiotics. A thousand years ago it was much worse, and more than ten thousand years ago it was worse still by another order of magnitude.

The journey that medicine took to arrive at where it is today was no straight path, involving many twists and turns. Sometimes, we took one step forward only to take two steps back (looking at you, organized religion). At first, people organized in hunter-gatherer groups learned through experimentation and cultural transmission which plants and foods were good to eat and which weren’t. For thousands of years, people used an array of plants and herbs prepared in various ways to treat wounds, infections, and all sorts of ailments through a painstaking process of trial and error.

It took many years, however, before complex medical procedures, such as surgery, were introduced. Performing surgery is incredibly risky and complicated – and amputations even more so. In order to safely amputate a limb, the person carrying out the operation needs proper anatomical knowledge and hygiene, as well as considerable technical skill.

Until the end of the 19^th century, it was very common to perform amputations without sterilization or even anesthesia. Among the 30,000 amputations performed during the American Civil War, for instance, there was a 26.3% mortality rate. But that was quite outstanding since, in the later 1870 Franco-Prussian War, the mortality rate of amputations was 76% despite the development of antiseptic surgical principles and effective anesthetics like chloroform discovered in 1847. This was the 19^th century – now imagine what it must have been like throughout history. Most people suffering amputations simply perished due to shock and blood loss, or a few days later from infection.

But when it worked, it saved people’s lives. Up until now, the earliest limb amputation occurred in modern-day France around 7,000 years ago, evidenced by the remains of a Neolithic farmer whose left forearm had been surgically removed and later healed.

No older evidence of surgical removal of body parts had been found before this point, apart from some finger amputations for punishment or symbolic purposes. There are some earlier reports of deliberate medical amputations of limbs among Neanderthals, but the evidence thus far is not conclusive, as the malformed limbs could have equally been the result of disease or an accident. The overwhelming assumption among scholars is that foraging societies simply could not amass the skill and techniques required to perform limb amputations.

The 31,000-year-old story of a Pleistocene medical breakthrough

All of this makes the discovery of the skeletal remains of the young Borneo individual with the amputated limb, known as “TB1”, even more extraordinary.

The Late Pleistocene “surgeon” who did the work must have had good knowledge of the leg’s anatomy, including the muscular and vascular systems to prevent fatal blood loss and infection. It seems highly unlikely the person performing the operation was simply lucky, severing tissue in exactly the right spots by hapchance. In fact, this was almost certainly not this surgeon’s first rodeo. Maloney is certain this was a medical amputation rather than the result of some accident or conflict.

“The remodeled bone at the amputation site, preserves clear signals of bone growth matching clinical instances of surgical amputation, completely lacking skeletal signals of infection or bone crushing otherwise associated with accidental injury or animal attack. Instead, the exceptionally clean, neat and oblique surfaces of the remaining left tibia and fibula, preserve clear instances of a sharp amputation surface, where the remodeled bone of some 6 to 9 years has formed, and partially fused, as the surviving individual put some pressure on the area throughout their life, liking using the lower left leg as a ‘stump’,” he said.

The scalpel may have been made from the sharp edge of a rock, bamboo, or even marine shells. “Sharp lithic edges are still used in niche aspects of modern surgery and found in immediate association with the buried individual, may support sharp chert (flint) flake edges as ancient scalpels – ongoing research is now examining these queries,” Maloney added.

The operation itself – however gruesome it must have been – was just one phase of the treatment. The individual whose left lower leg was cut off had to be regularly fed, bathed, and have their wounds cleaned. Perhaps the patient was even given anesthetics and antiseptics concocted from locally available plants. Borneo is a hot spot of plant biodiversity and wound infections in the tropics are much more common than in other parts of the world like Europe, so foraging communities could have had more opportunities to learn what natural pharmaceuticals had antiseptic effects.

“In western societies for comparison, amputation resulted in death as often as not, until antiseptics became widely used within the past century or so – implying a fair likelihood that this technological development was also possessed by the ancient surgeons of Borneo, who likely also stemmed blood loss and managed shock. It is highly unlikely for an individual to survive an open wound of this nature, without a high degree of antiseptic, antimicrobial and even pain relief remedies — we suspect likely accessed via the immense plant biodiversity in the tropical rainforest environments of the area,” Maloney said.

It all must have worked wonderfully since the Borneo individual – who must have been a child at the time of surgery — did not seem to suffer from infection – at least not the kind to leave permanent lesions on the bones or cause death. The patient then survived between six to nine years following his surgery, before being buried within the Liang Tebo limestone cave, found in East Kalimantan. Previously, explorers navigating through the three-chambered limestone cave found figurative rock art dating to at least 40,000 years ago.

The entire area surrounding Liang Tebo is, in fact, a very rugged karst terrain with many caves and rock shelters dotting the landscape. It’s no wonder the area was occupied by humans since the late Pleistocene epoch, but the rugged landscape can also be unforgiving. It’s hard enough trekking through it on two, healthy legs, let alone on one.

Without community care, TB1 would have been killed by his amputation within days, if not hours – a true testament to what humanity truly means from a group of people some would call ‘primitive’.

“This archaeological discovery adds to a steadily building case for the immense complexity and societal advancements of ancient human life during the late Pleistocene – with cultural heritage providing something of a recipe for sustainable life on earth, one capable of thriving with art, advanced medicine and a high degree of community care. This finite cultural heritage record in precious, valuable yet also threatened – and in need of heightened value across the world,” Maloney concluded.