Surgical amputation of a limb 31,000 years ago in Borneo

This study investigates whether complex surgical interventions, specifically limb amputation, existed among Late Pleistocene forager populations. The context is a long-standing hypothesis that sophisticated medical practices emerged primarily with Neolithic sedentism. By examining a burial from Liang Tebo cave (East Kalimantan, Borneo) within a well-dated stratigraphic context and analyzing skeletal evidence for trauma and healing, the authors aim to reassess the timing and sophistication of prehistoric medical knowledge among mobile foragers in tropical Asia.

Prior to this discovery, the oldest widely accepted case of surgical amputation was a Neolithic farmer from France (~7,000 years ago), interpreted as evidence of advanced anatomical knowledge and technical skill in early agricultural societies. Other prehistoric medical interventions noted among foragers include suturing, dentistry, cranial trepanation, and various body modifications, but complex surgeries were thought beyond their capabilities. Reports of deliberate amputation among Neanderthals are considered inconclusive, though they evidence medical care. The new Borneo case challenges the narrative that advanced surgery arose only with the Neolithic.

• Site and excavation: Liang Tebo, a three-chambered limestone cave in the Sangkulirang–Mangkalihat Peninsula, East Kalimantan (Indonesian Borneo). A 2 × 2 m trench was excavated to a depth of 1.5 m in 2020 following geophysical survey. A distinct burial feature with limestone rocks placed above the head and arms was identified, indicating a deliberate, manufactured grave.
• Recording: The burial (TB1) was documented in 32 excavation spits with laser scanning and photography. The skeleton shows ~75% bone integrity and is well preserved.
• Osteological analysis: Morphological assessments identified the individual as Homo sapiens. Age-at-death was estimated at ~19–20 years using epiphyseal fusion, pubic symphysis, auricular surface stages, and dental formation. Sex is indeterminate due to intermediate traits. Stature compared with regional Late Pleistocene samples indicates typical male range but data overlap precludes firm sexing.
• Stratigraphy and dating: Charcoal immediately above the grave (SU7) returned calibrated AMS 14C ages of 31,130–30,437 cal BP; charcoal from the grave lid yielded 31,100–30,437 cal BP (D-AMS83373). Charcoal from the underlying stratum (SU9) provided 31,519–31,304 cal BP (D-AMS83363). Bayesian modeling indicates a burial age bracket of 31,519–30,437 cal BP, with modeled boundary estimates around 30,853 ± 770 cal BP (SU7/SU8) and 31,115 ± 864 cal BP (beneath). Depth–age relationship shows strong positive correlation (r = 0.990, r² = 0.981), indicating minimal reworking. Uranium-series/electron spin resonance (ESR) dating on a left mandibular molar yielded 25.4 ± 3.3 ka; incorporated into the Bayesian model this supports a modeled burial age of 31,210–30,714 years ago (95% probability). Direct radiocarbon dating of bone failed due to insufficient collagen; U-series on bone was limited by low uranium.
• Paleopathology and imaging: The left lower leg exhibited complete absence of the distal third of tibia and fibula; remodeled amputation surfaces with bone healing were documented macroscopically, radiographically, and with digital microscopy. Evidence included oblique sectioning margins, remodeling with closure of distal fibula, partial tibia-fibula consolidation, and lack of crush or comminution indicative of accidental trauma. Comparative assessment of right tibia cortical thinning and left leg atrophy indicated reduced mobility. Developmental size of left tibia/fibula implies injury occurred in childhood (~6–9 years).

• The TB1 individual (Homo sapiens) was a young adult (~19–20 years at death) intentionally buried at Liang Tebo.
• The distal third of the left tibia and fibula are absent, with remodeled, healed amputation surfaces and complete closure of the distal fibula consistent with late-stage changes after surgical amputation.
• Osteological indicators (bone remodeling, absence of crushing/comminution, oblique sectioning) rule out common non-surgical causes (accidents, animal attacks, punitive mutilation). No evidence of infection is present.
• The small size of the left tibia/fibula and remodeling indicate the amputation occurred in childhood (estimated 6–9 years), with survival for at least 6 years post-procedure.
• Dating constraints: calibrated AMS 14C charcoal ages bracketing the burial at 31,519–30,437 cal BP; Bayesian model including ESR tooth date yields 31,210–30,714 years ago (95% probability). This makes TB1 the oldest known intentional primary burial with evidence of successful limb amputation in Island Southeast Asia and, to current knowledge, globally predating the previously accepted ~7,000-year-old case.
• Skeletal indicators suggest TB1 was rarely ambulatory due to the injury, with muscular and osseous atrophy in the affected limb and some cortical thinning in the right tibia from reduced overall mobility.

The evidence demonstrates that a complex surgical intervention—successful distal lower-leg amputation—was performed on a forager child in tropical Asia around 31,000 years ago. Survival for years post-surgery without osteological signs of infection implies competent wound management, knowledge of anatomy (including vascular control), and effective postoperative care within the community. These findings challenge the prevailing view that forager healthcare was limited to simple procedures and that advanced surgery emerged only with the Neolithic. Instead, at least some Late Pleistocene foragers possessed sophisticated medical knowledge and social systems capable of supporting disabled individuals, reshaping narratives about the evolution of medicine and care in human societies.

This study documents the earliest known case of successful limb amputation, from a Late Pleistocene forager buried at Liang Tebo, Borneo. Stratigraphic and chronological evidence securely place the burial between ~31,500 and ~30,400 cal BP, and osteological analyses confirm a healed surgical amputation performed in childhood with long-term survival. The findings imply that sophisticated surgical skills and healthcare existed among tropical Asian foragers long before the Neolithic transition, revising models of the development of complex medical practices. Future research should expand systematic surveys and excavations in the region, apply multi-proxy dating to additional burials, and investigate botanical and cultural evidence that might illuminate prehistoric medical knowledge, including anesthetics, antiseptics, and postoperative care practices.

• Single-case evidence limits generalizability about the prevalence of complex surgery among Pleistocene foragers.
• Direct dating of the skeleton was unsuccessful due to insufficient collagen and low uranium; chronology relies primarily on associated charcoal and modeled integration of a tooth ESR date with larger uncertainty.
• Sex determination is indeterminate, and some skeletal elements are missing or only ~75% complete overall, which may constrain certain inferences.
• Some stratigraphic and text-transcription ambiguities exist in the report; however, the age–depth model shows no inversion, supporting minimal post-depositional disturbance.