In Bangladesh, clinical records of 323 patients with typhoid fever were reviewed to study the incidence, fatality, and optimal therapy of the complication of intestinal perforation. Fifteen patients (4.6%) developed intestinal perforation. Case-fatality rates were six of nine patients treated medically and one of four patients treated surgically for whom the postoperative courses were known. A literature review of 57,864 cases of typhoid fever in developing countries in the antibiotic era revealed that perforation developed in 2.5% of patients, a percentage that was similar to the incidence of 2.8% reported in the preantibiotic era. The median of case-fatality rates in these reports was 43% and the proportion of all reported typhoid deaths attributable to perforation was 25%. The case-fatality rates for patients with perforation were 70% for 410 patients managed medically and 26% for 1,835 patients managed surgically. Although some reports were biased toward placing patients at lower risk into surgical treatment, the large number of patients treated successfully by surgery suggests real improvement in surgical techniques in countries with endemic typhoid fever. These results indicate that intestinal perforation persists as a major cause of death in cases of typhoid fever in developing countries in the antibiotic era and that surgical treatment with use of antibiotic therapy is optimal for this complication.