The amputation happened when the individual was perhaps 12 years old, the skeleton indicates. Gone is the lower portion of the left leg. And somehow, the individual survived the surgical procedure — a remarkable feat given that it happened some 31,000 years ago.
The skeleton, discovered in a cave on Borneo, in what is now Indonesia, appears to be evidence of the oldest known surgical amputation — 24,000 years earlier than that of a farmer in France, who had his left arm cut off an estimated 7,000 years ago.
The newly identified amputation occurred when the individual was a child living in a hunter-gatherer society, a team of Indonesian and Australian archaeologists reported Wednesday in the journal Nature. The child — the researchers did not determine the sex — lived for another six to nine years, ultimately dying at 19 or 20 years old, according to analyses of the skeleton.
The procedure happened so long ago that this part of Indonesia was connected to mainland southeast Asia because of lower sea levels.
“This is a really strong case that this [surgeon] and the community had developed advanced medical understandings to be able to successfully amputate the lower left leg of a child, enabling them to not only survive the procedure but live quite a thriving life in this environment into their adulthood,” said Tim Maloney of Australia’s Griffith University, the lead author of the paper.
Amputation requires technical skill, anatomical knowledge, and a battle against the elements. Surgeons have to guard against infections; navigate nerves, muscles, and blood vessels; sedate patients and control their pain (ideally); and cut through bone. People surviving amputations only became the norm far more recently, Maloney said, thanks in part to antiseptic advancements starting in the late 19th century.
The amputation in France from 7,000 years ago fit with the view that as people moved from foraging to agricultural societies, they started to develop more innovative medical practices.
The new study challenges that perception. An analysis of the Bornean bones led the researchers to rule out causes like a traumatic accident or animal attack and to conclude it was a “deliberate surgical amputation.” The bones also showed signs of healing and no lasting indication of infection, and the fact that the individual lived several years shows infection was not a major issue. Moreover, the successful procedure signals that the prehistoric surgeon or surgeons knew how to stanch blood loss.
Such a surgery also raises the possibility that the society knew how to use plant species for sedation, pain, and infection control. And it suggests that other individuals in this society helped the child recover from the surgery and live on in the mountainous terrain.
“That this child survived the procedure and is estimated to have lived for many years afterwards is astounding,” Charlotte Roberts, a bioarchaeologist at Durham University, wrote in an editorial also published in Nature Wednesday.
The study’s authors cautioned that they don’t know how widespread this surgical skill and knowledge might have been at the time or whether other successful amputations might have happened then as well.
The skeleton was found in a limestone cave called Liang Tebo in an area that’s home to some of the earliest known pieces of rock art. The archaeologists were excavating a burial site there when they came across a skeleton missing the bottom portion of its left leg, with the tibia and fibula cut.
Benjamin Miller is an orthopedic surgeon at the University of Iowa who performs amputations and was not involved in the new research. Upon reading the paper, he marveled about such details as how the surgeons back then managed blood loss and infection.
He pointed to another mystery as well. Even today, “if you have something like a sharp steel instrument that’s a little bit dull, it doesn’t do the job,” Miller said. “I just can’t figure out how they would cut the bone.”
Maloney said there were a few hypotheses about what kind of scalpel might have been used. Sharpened shells and bamboo are theoretical options, he said, though he added that both “are, clinically, shall we say, less than ideal edges for surgical precision.” The most likely answer then, Maloney said, was a stone edge.
Get your daily dose of health and medicine every weekday with STAT’s free newsletter Morning Rounds. Sign up here.