Despite decades of experience with congenital syphilis, problems still arise in case definition, diagnostic evaluation, treatment, and follow-up. We reviewed all 50 cases of early congenital syphilis reported to the State of Texas in 1982. A large proportion of the infants were premature (39%), of low birth weight (38%), and symptomatic at birth (62%). Because of these findings, we believe that possible cases of asymptomatic congenital syphilis in Texas may be under-reported. Laboratory and/or roentgenographic findings were important to confirm the diagnosis of congenital syphilis. Over half of the asymptomatic infants had positive results of cerebrospinal fluid VDRLs. After diagnosis, the treatment of infants with penicillin varied considerably. While all 47 living infants were treated with penicillin, 21 different regimens were used. We urge all physicians to perform complete diagnostic evaluations on suspected infants consisting of a quantitative serum test for syphilis, serum IgM levels, a cerebrospinal fluid VDRL, roentgenographs of the long bones, and dark-field microscopy where indicated. Additionally, infants and their families need appropriate follow-up after treatment.