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 Pediatric Diagnosis: Atlas of Disorders of Surgical
Significance Spencer W. Beasley

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 Paediatric Surgical
Diagnosis
Atlas of Disorders of Surgical Significance

SECOND EDITION

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K31261_Book.indb 2 4/16/18 4:48 PM
 Paediatric Surgical
Diagnosis
Atlas of Disorders of Surgical Significance
SECOND EDITION

Spencer W. Beasley
Paediatric Surgeon, Christchurch Hospital
Professor of Paediatric Surgery, Departments of Paediatrics and Surgery, University of Otago
Christchurch, New Zealand

John Hutson
Paediatric Urologist, The Royal Children’s Hospital
Chair of Paediatric Surgery, Department of Paediatrics, University of Melbourne
Melbourne, Australia

Mark Stringer
Paediatric Surgeon, Wellington Hospital
Honorary Professor, Department of Paediatrics & Child Health, University of Otago
Wellington, New Zealand

Sebastian K. King
Paediatric Surgeon, The Royal Children’s Hospital
Clinical Associate Professor, Department of Paediatrics, University of Melbourne
Melbourne, Australia

Warwick J. Teague
Paediatric Surgeon & Director of Trauma Services, The Royal Children’s Hospital
Clinical Associate Professor, Department of Paediatrics, University of Melbourne
Melbourne, Australia

K31261_Book.indb 3 4/16/18 4:48 PM

 CRC Press
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© 2018 by Taylor & Francis Group, LLC

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Library of Congress Cataloging‑in‑Publication Data

Names: Beasley, Spencer W., author. | Hutson, John M., author. | Stringer,
Mark D., author. | King, Sebastian, author. | Teague, Warwick J., author.
Title: Pediatric diagnosis : atlas of disorders of surgical significance /
Spencer Beasley, John Hutson, Mark D. Stringer, Sebastian King, Warwick
Teague.
Description: Second edition. | Boca Raton : CRC Press, [2018] | Includes
bibliographical references and index. |
Identifiers: LCCN 2017052034 (print) | LCCN 2017052272 (ebook) | ISBN
9781315279978 (eBook General) | ISBN 9781315279961 (eBook PDF) | ISBN
9781315279954 (eBook ePub3) | ISBN 9781315279947 (eBook Mobipocket) |
ISBN 9781138197329 (pbk. : alk. paper)
Subjects: | MESH: Diagnostic Techniques, Surgical | Child | Infant | Atlases
Classification: LCC RD137.3 (ebook) | LCC RD137.3 (print) | NLM WO 517 | DDC
617.9/8--dc23
LC record available at https://lccn.loc.gov/2017052034

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K31261_Book.indb 4 4/16/18 4:48 PM

 Contents

Foreword to the first edition vii Lateral neck lumps 79

Foreword to the second edition ix The eye 80
Nystagmus 80
Acknowledgements xi
Strabismus 80
Contributors xiii The white pupil (leukocoria) 80
Introduction xv Ptosis 81
Specific syndromes 81
1 Antenatal diagnosis 1
4 The thorax 129
2 Major neonatal conditions 11 Chest wall deformities 129
Ventral abdominal wall defects 11 Primary chest wall deformities 129
Exstrophy 11 Secondary or acquired chest wall
Prune belly syndrome 11 deformities 129
Anorectal malformations 11 The lungs 129
Ambiguous genitalia (disorders of sexual Congenital lobar emphysema 129
development [DSD]) 12 Congenital pulmonary airway
Congenital diaphragmatic hernia 13 malformation 130
Oesophageal atresia 13 Pulmonary sequestration 130
Intestinal atresias 14 Bronchogenic cyst 130
Meconium ileus 14 Pulmonary interstitial emphysema 130
Hirschsprung disease 15 Miscellaneous pulmonary conditions 130
Neonatal necrotising enterocolitis 15 The pleural cavities 130
Neural tube defects 15 The mediastinum 130
Conjoined twins 16 The oesophagus 131
Sacrococcygeal teratoma 16 The diaphragm 131
The breast 131
3 Head and neck 77
The skull 77 5 The abdomen 161
Hydrocephalus 77 Pyloric stenosis 161
Craniosynostosis 77 Intussusception 161
Encephalocele 77 Appendicitis 161
External angular dermoid 77 Meckel diverticulum 162
The ear 77 Other causes of the acute abdomen 162
Superficial infection 78 Constipation 162
Parotid region 78 Gastro-oesophageal reflux 163
The lip 78 Intra-abdominal tumours 163
The tongue 78 Inflammatory bowel disease 163
Mouth, gums and pharynx 78 The anus and perineum 164
Choanal atresia 79 Rectal bleeding 164
Larynx and trachea 79 Rectal prolapse 164
Midline cervical swelling 79 Jaundice 165

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 vi ContEnts

Portal hypertension 165 Perthes disease 281

Cholelithiasis 166 Slipped upper femoral epiphysis 281
The spleen 166 Legs 281
The pancreas 166 Feet 281
Hands and fingers 282
6 The abdominal wall and Scoliosis 282
inguinoscrotal conditions 209 Osteomyelitis 282
The umbilicus 209 Septic arthritis 282
The penis 209 Semimembranosus bursa 282
Phimosis 209 Ganglion 282
Paraphimosis 210 Miscellaneous deformities 282
Hypospadias 210 Neoplasms 283
Miscellaneous conditions of the penis 210 Superficial infection 283
The ‘acutely painful scrotum’ 210 Vascular anomalies 283
Hernias and hydroceles 211 Vascular tumours 283
Undescended testis 211 Vascular malformations 284
Varicocele 212 Vascular obstruction 284
Sacrococcygeal teratoma 212 Melanocytic naevi 284
Epidermal naevi 285
7 The urinary tract 247
Investigations 247 10 Trauma 331
Wilms tumour 247 Abdominal and thoracic injuries 331
Pelviureteric obstruction 247 Urological injuries 331
Vesicoureteric obstruction 248 Soft tissue injuries 332
Vesicoureteric reflux 248 Fractures 332
Ureterocele 248 Upper limb fractures 332
Double kidneys and ureters 248 Lower limb fractures 332
Urinary tract stones 248 Non-accidental injury (child abuse) 333
Posterior urethral valve 248 Burns 333
Rare urethral anomalies 248 Inhalation injury 333
Caustic ingestion 333
8 Gynaecological conditions 273 Foreign bodies 334
Female genitalia and gynaecological
Ocular injuries 334
conditions 273
Head injuries 335
Perineal masses 273

Further reading 385

9 The limbs and soft tissues 281
Hips 281 Index 387

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 Foreword to the first edition

Paediatric surgery is age-related general surgery in a broad photographs, x-rays and other imaging studies. In addition to
sense, involving many specialty fields. This book represents marvellous illustrations, good descriptive legends and a con-
the essential elements of the multifaceted nature of the sur- cise text present a list of differential diagnoses and at least one
gery of infancy and childhood. reliable approach to confirmatory studies where appropriate.
Three very experienced individuals with well-recognised No attempt is made to be exhaustive in the treatment of
expertise in clinical care, education and research wrote this any disorder, which makes this book particularly useful for
book. They have worked their entire careers in one of the most the intended audience around the world. The authors advise
important children’s centres in the world, so this book brings their readers to use this book in conjunction with a stan-
with it a level of authority which is unmatched. dard text for comprehensive coverage, but it would certainly
The authors’ goal was to develop an illustrated guide to stand alone as a visual guide to rapid diagnosis of almost
diagnosis of the important paediatric surgical conditions. any ­paediatric surgical condition likely to be seen in routine
The common, the occasional and some rare conditions are practice. This book is well organised into sections, which are
all here. Although it would be virtually impossible to include comprehensively treated. In addition to conditions usually
every conceivable rare disorder, the authors come close; and treated by general paediatric surgeons, those treated by oph-
certainly every condition likely to be encountered in a prac- thalmologists, neurosurgeons, urologists, otolaryngologists,
titioner’s professional life time is presented including entities orthopaedists and plastic surgeons are covered. Neonatal as
seen mainly in third world countries. There is a great need for well as acquired disorders are included. A book like this could
a book of this nature, which teaches the basics that trainees are only have come from the life’s work of three such experienced
frequently not taught today as high-tech medicine is empha- paediatric surgeons.
sised. The emphasis is on primary care and additional manage-
ment geared for medical students, trainees and practitioners in James A. O’Neill, Jr, MD
paediatrics, obstetrics and various surgical specialities, as well C. Everett Koop Professor of Paediatric Surgery
as nurses who might need a quick reference for diagnosis. University of Pennsylvania, School of Medicine
The particularly valuable aspect of this pictorial text is Surgeon-in-Chief, Children’s Hospital of Philadelphia
that it stresses physical diagnosis illustrated by beautiful Philadelphia, PA, USA

vii

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K31261_Book.indb 8 4/16/18 4:48 PM
 Foreword to the second edition

This second edition of Atlas of Paediatric Surgery, now titled assessment and intervention were possible previously, these
Paediatric Surgical Diagnosis: Atlas of Disorders of Surgical have become a standard aspect of care in the time interval
Significance, is a superbly illustrated and well-organized since the first edition was published. These areas are addressed
guide to most common anomalies in children’s surgery as in chapter one, while the second chapter is dedicated to major
well as many that are uncommon. While this text is not congenital anomalies which would be symptomatic or appar-
intended to be encyclopaedic in scope, it does present in con- ent in the neonatal period. Together these chapters will be
siderable depth the broad spectrum of general and thoracic quite useful to any who wish to understand newborn surgi-
paediatric surgery, as well as offer an important perspec- cal anomalies. The introductory chapters are followed by
tive to any children’s provider in paediatric urology, head anatomical and organ system presentations, concluding with
and neck surgery, ophthalmology, orthopaedics, neurosur- trauma and gynaecological conditions. The overall focus is
gery and, indeed, all of children’s surgery. The emphasis is on visual clarity and a pragmatic bedside clinical approach to
on providing photographs and illustrations to assist in the these children with surgical needs. The atlas is designed not
recognition, clinical understanding and multidisciplinary as a comprehensive surgical reference text or operating atlas,
management of the various abnormalities. This edition but as a companion or adjunct to such standard presentations,
builds on the first; it is not only beautifully photographed adding a depth of understanding and visual diagnostic clarity
and illustrated, but it is improved in the organization and that is unique. It will be a valuable addition to the libraries of
clarity of the supporting text. Taken together, the succinct institutions and individuals who care for children with sur-
narratives and lucid visual presentations make the text use- gical needs. This includes not just general and thoracic pae-
ful to a broad audience. Children’s surgery encompasses diatric surgeons but all children’s surgeons, as well as other
such diverse pathology that collection of this information, allied health professionals, those who are learning about these
and particularly these photographs, would take most indi- patients, including residents, fellows and students, and indeed
viduals several careers to compile. The authors have done anyone with an interest in the surgical problems of infants
this for the reader with emphasis on diagnostic information and children.
including radiographic and other imaging, as well as intra-
operative photographs. The presentation is uniquely infor- Keith T. Oldham, MD
mative in aggregate. Professor of Surgery, Division of Pediatric Surgery
The atlas is edited by five of the most senior and well rec- Medical College of Wisconsin
ognized children’s surgeons in the world. All are experts and Marie Z. Uihlein Chair of Pediatric Surgery
bring a wealth of clinical experience to this work. The authors and Surgeon-in-Chief
have added new information in this edition, particularly Children’s Hospital of Wisconsin
related to antenatal diagnosis and treatment. While in-utero Milwaukee, WI, USA

ix

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K31261_Book.indb 10 4/16/18 4:48 PM
 Acknowledgements

ACKNOWLEDGEMENTS FOR THE copying (and maintaining in order) a large number of slides,
FIRST EDITION and to produce a number of line drawings. Their full coopera-
tion in this project over many months has made the editors’
No one surgeon, not even one in the busiest clinical practice, task much easier.
could collect the range and variety of conditions displayed The secretarial staff of the Department of Surgery, Elizabeth
in this atlas within a lifetime. Therefore, despite fairly exten- Vorrath and Judith Hayes, now well used to the rigours of medi-
sive collections of our own, we have been heavily reliant on cal manuscripts, have confirmed their mastery of complex,
the contributions of a number of colleagues. Many of these numerous and ever-changing legends. Their efficiency and good
have gone to considerable effort to provide us with as com- humour has obscured any frustrations they might have had.
prehensive a coverage of the specialty as possible, and to them Our ever-patient families have provided the support that
we are extremely grateful. They include: Alex Auldist, John has allowed us to devote consecutive long weekends to the
Barnett, Don Cameron, Tony Catto-Smith, Bill Cole, David project. We are happy to return the time to them in full now
Croaker, Paddy Dewan, Bob Dickens, James Elder, Roger Hall, it is completed.
David James, Peter Jones, Anne Kosloske, Julian Keogh, Geoff Finally, we are grateful to Peter Altman who encouraged us
Klug, Neil McMullin, Azad Najmaldin, Kevin Pringle, T.M. to embark on the project and who has provided helpful guid-
Ramanaujam, Barry Shandling, Errol Simpson, Arnold Smith, ance throughout. The professional work of Chapman and Hall
Durham Smith, John Solomon, Douglas Stephens, Keith has been a major factor contributing to this work, which we
Stokes, Russell Taylor, Roger Voigt, Alan and Susie Woodward. hope will be of use to paediatric surgical aspirants and teach-
Ramanujam, in particular went to extraordinary lengths to ers for many years to come.
provide us with a fine series of slides of the most bizarre and
rare conditions. We are grateful to our many registrars who ACKNOWLEDGEMENTS FOR THE
have had to organise the photography of many of the lesions.
Slides of interesting cases often are passed between col-
SECOND EDITION
leagues and, with time, their origin may become obscure. It is Once again we are indebted to The Royal Children’s Hospital
quite possible that a number of illustrations included in this Creative Studio (previously Educational Resource Centre) for
atlas have not been acknowledged appropriately. To those who their expert assistance in taking many of the clinical pho-
have the original source of these illustrations, we are truly tographs as well as dealing with the artwork and digital file
grateful, despite their anonymity. management.
An enormous contribution has been made by staff of the We thank Shirley D’Cruz, Personal Assistant to Professor
Educational Resource Centre of The Royal Children’ Hospital, John Hutson, who worked tirelessly to prepare the base texts
Melbourne, who have been happy to bear the burden of and image legends for revision. Shirley then shouldered the

Fig. 1 The authors (from left to right): Spencer Beasley, Mark Stringer, Warwick Teague, Sebastian King
and John Hutson. xi

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 xii AcKnowLEdGEmEnts

lion’s share of the responsibility for ensuring version control to Peter Beynon and Paul Bennett, the meticulous care they
throughout the complex task of revising the text and legends, have taken assembling a substantial file of figures, and their
and managing the nuances and needs of five editors and a detailed understanding of what we have tried to achieve, has
publisher across three time zones. made our work so much easier.
Many of the original photographs provided in the first e­ dition Creating an atlas of this magnitude takes an enormous
have been retained. In addition, we have included photographs amount of time: this time is often at the end of an already
and images provided by the listed contributors to this edition. long day, and it is time that otherwise would have been spent
The staff of CRC Press throughout have been wonderfully with our wives and families. So it is to Christy, Susan, Alice,
patient and understanding of us, particularly in the final Charlotte and Kirsty, and our respective children, who have
stages where the actual layout and accuracy of the figures had to tolerate and forgive us our absences during the prepa-
and their legends has become important. From Cherry Allen, ration of this book, that we are so grateful.

K31261_Book.indb 12 4/16/18 4:48 PM

 Contributors

Raimah Ahmed Aniruddh Deshpande Michael Johnson

Urology Resident Paediatric Surgeon Orthopaedic Surgeon
The Royal Children’s Hospital John Hunter Children’s Hospital The Royal Children’s Hospital
Melbourne, Australia Newcastle, Australia Melbourne, Australia

Keith Amarakone Andrew Dobson Basil Leodoro

Trauma Fellow Paediatric Surgical Registrar General Surgeon
The Royal Children’s Hospital Christchurch Hospital Ministry of Health
Melbourne, Australia Christchurch, New Zealand Port Vila, Vanuatu

Katherine Baguley Leo Donnan Parkash Mandhan

Otorhinolaryngologist Orthopaedic Surgeon Paediatric Surgeon
Wellington Regional Hospital The Royal Children’s Hospital Christchurch Hospital
Wellington, New Zealand Melbourne, Australia Christchurch, New Zealand

Elhamy Bekhit Charlotte Elder Kiki Maoate

Radiologist Adolescent Gynaecologist Paediatric Surgeon
The Royal Children’s Hospital The Royal Children’s Hospital Christchurch Hospital
Melbourne, Australia Melbourne, Australia Christchurch, New Zealand
Aurore Bouty James Elder Jay Marlow
Urologist Ophthalmologist Maternal and Fetal Medicine Specialist
The Royal Children’s Hospital The Royal Children’s Hospital Wellington Regional Hospital
Melbourne, Australia Melbourne, Australia Wellington, New Zealand
Brendon Bowkett Louise Goossens
Paediatric Surgeon Stephen McInally
Senior Medical Photographer Medical Photographer
Wellington Children’s Hospital Wellington Regional Hospital
Wellington, New Zealand University of Newcastle
Wellington, New Zealand Newcastle, Australia
Chris Coombs Mary-Louise Greer
Plastic and Reconstructive Surgeon Randal Morton
Radiologist
The Royal Children’s Hospital Otorhinolaryngologist
Hospital for Sick Children
Melbourne, Australia Auckland, New Zealand
Toronto, Canada
Charles Davis Sonia Grover Cameron Palmer
Craniofacial Surgeon Adolescent Gynaecologist Trauma Data Manager
Wellington Regional Hospital The Royal Children’s Hospital The Royal Children’s Hospital
Wellington, New Zealand Melbourne, Australia Melbourne, Australia

Jan de Faber Haytham Kubba Tony Penington

Ophthalamologist Paediatric Otorhinolaryngologist Plastic and Reconstructive Surgeon
Rotterdam Eye Hospital The Royal Children’s Hospital The Royal Children’s Hospital
Rotterdam, The Netherlands Melbourne, Australia Melbourne, Australia

Phillipa Depree Simon John Rod Phillips

Paediatric Radiologist Paediatric Neurosurgeon General Paediatrician
Christchurch Hospital Christchurch Hospital The Royal Children’s Hospital
Christchurch, New Zealand Christchurch, New Zealand Melbourne, Australia

xiii

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xiv ContrIButors

TM Ramanajum Alice Stringer Zacharias Zachariou

Paediatric Surgeon Otorhinolaryngologist Paediatric Surgeon
University of Malaya Wellington Regional Hospital University of Nicosia
Kuala Lumpur, Malaysia Wellington, New Zealand Nicosia, Cyprus

Elizabeth Rose Prue Weigall Augusto Zani

Otorhinolaryngologist Physiotherapist Paediatric Surgeon
The Royal Children’s Hospital The Royal Children’s Hospital Hospital for Sick Children
Melbourne, Australia Melbourne, Australia Toronto, Canada

Victoria Scott
Paediatric Surgeon Jonathan Wells
Christchurch Hospital Paediatric Surgeon
Christchurch, New Zealand Christchurch Hospital
Christchurch, New Zealand
Anne Smith
Forensic Paediatrician Toni-Maree Wilson
Victorian Forensic Paediatric Medical Paediatric Surgeon
Service Wellington Hospital
Melbourne, Australia Wellington, New Zealand

K31261_Book.indb 14 4/16/18 4:48 PM

 Introduction

More than any other specialty, with the possible exception of to 9 deal with the regions of the body sequentially, working
dermatology, paediatric surgery lends itself to an illustrated from the head and neck, through the trunk, to the limbs.
guide to diagnosis. In the neonate, the dramatic appearance Abnormalities of the respiratory, gastrointestinal and urinary
of exomphalos, gastroschisis, bladder exstrophy and prune systems may be associated with a variety of external clinical
belly syndrome is obvious. Anorectal malformations pres- manifestations but, more often than not, the definitive diag-
ent with a spectrum of features, some of which are quite nosis is made only after specialised radiological investigation
subtle, but which can be demonstrated with careful clinical or at operation. Consequently, the operative views illustrate
examination. Even some internal lesions, such as volvulus, those conditions in which a diagnosis is made at surgery, or
meconium ileus and bowel atresia, have external features, where the operative appearance is characteristic and clarifies
such as abdominal distension. The majority of orthopaedic the diagnosis. No attempt has been made to include details of
­deformities and inguinoscrotal lesions are diagnosed entirely operative technique. In the chapter on trauma, which covers
on clinical grounds, most of which can be illustrated clearly all systems, special emphasis is given to non-accidental injury
on photography. Likewise, abnormalities and lesions of the and in particular sexual abuse, as this is an area of consider-
head and neck, which are common in this age group, are usu- able importance, and the clinician must be aware of the rel-
ally superficial or structural, enabling easy clinical diagnosis. evant features.
The relatively obscure areas of the thorax and urinary tract There are three major limitations to any pictorial guide to
may have few or vague clinical features, but become apparent diagnosis. First, given the limitations of length, it is impos-
on appropriate radiological or other types of imaging. sible to include all conditions or their variations. For example,
This illustrated guide to the diagnosis of paediatric surgical the sections on anorectal malformations or disorders of sex-
disorders sets out to cover the broad spectrum of abnormali- ual differentiation are extensive but not comprehensive: they
ties encountered in this specialty. Although we have concen- could be vastly expanded, but for the sake of a relatively con-
trated on the common lesions, we have deliberately included cise book this is not feasible. Second, many well-­recognised
some extremely rare conditions to highlight the enormous conditions occur extremely rarely and, even in a large institu-
variation that one may encounter in a specialty that includes tion, certain conditions may be seen only once every decade
bizarre congenital abnormalities. or so. If they are not captured on film at the time of presenta-
The first chapter focuses on antenatal diagnosis, in recog- tion, and before their operative correction, it may take some
nition of the fact that nowadays most structural congenital time before another similar case presents. In this regard, the
abnormalities are diagnosed antenatally, and the paediatric editors are grateful to the many contributors who have helped
surgeon becomes involved in the care of the unborn infant ‘fill the gaps’. Third, some conditions have no external clinical
and its family well before birth. In this chapter we have delib- or radiological features that lend themselves to photography,
erately included the type of ultrasound images encountered which means that they tend to be ‘down-played’ in a pictorial
by paediatric surgeons in their everyday practice rather than book of this type. This is not to ignore or deny their impor-
concentrating on some of the recently introduced but not tance, but obviously those conditions that are easily demon-
always widely available ‘state of the art’ imaging techniques. strated photographically will tend to gain greater prominence.
The second chapter deals with major neonatal abnormalities For this reason, it is important that this book should be read
that are apparent at, or shortly after, birth; some will have in conjunction with a standard paediatric surgery text if com-
been diagnosed several months prior to birth. Chapters 3 prehensive coverage of the specialty is required.

xv

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K31261_Book.indb 16 4/16/18 4:48 PM
 CHAPTER
Antenatal diagnosis
1
Antenatal diagnosis of major congenital abnormalities in the are less severe and who survive long enough to reach birth –
fetus has become commonplace as a result of the increasing and surgical attention – are already a selected group in whom
use and sophistication of antenatal ultrasonographic equip- good surgical results would be expected. The range of abnor-
ment. Initially, it was thought that the antenatal diagnosis malities detectable by antenatal ­ultrasound scanning includes
of fetal abnormalities would lead to better treatment and an anencephaly, spina bifida, hydrocephalus, encephalocele, car-
improved outcome, but so far, this expectation has only been diac abnormalities, urinary tract obstruction, congenital lung
partly fulfilled. Nevertheless, there is little doubt that peri- malformations, congenital diaphragmatic ­ hernia, ovarian
natal treatment of several abnormalities is improved by their cysts, ventral abdominal wall defects, duodenal atresia and
foreknowledge. gross skeletal abnormalities.
Between 18 and 21 weeks of gestation is regarded as the For a time it was hoped that early antenatal recognition
best time for the early detection of most fetal abnormalities, of some of these conditions (e.g. congenital diaphragmatic
although if there is a previous history of fetal abnormalities hernia, hydrocephalus and urinary tract obstruction) would
(e.g. spina bifida) an ultrasound examination earlier in preg- allow intrauterine fetal surgery to prevent ongoing or second-
nancy may be indicated, with either repetition of the ultra- ary injury to the fetus, but so far the results of fetal surgery in
sound scan at suitable intervals throughout the pregnancy or all but a few highly selected conditions have been disappoint-
progression to more invasive tests, such as amniocentesis, cho- ing. Perhaps the main value of antenatal diagnosis is that the
rionic villus and fetal blood sampling. Antenatal diagnosis of affected infant can be delivered at a tertiary institution and
fetal abnormalities has identified a group of severely affected the appropriate treatment initiated at birth. This may avoid
fetuses with complex lethal abnormalities which in the past some of the problems of neonatal transport and of delayed
never survived the pregnancy. Those with abnormalities that diagnosis.

Fig. 1.1 An abortus with an intact amniotic sac containing Fig. 1.2 Exomphalos in a 12-week fetus showing prolapse of
a fetus within it. At least 10% of pregnancies abort in the the liver into the sac.
embryonic stage (the first 8 weeks of gestation), mostly from
chromosomal anomalies or gross malformations.

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 2 ANTENATAL DIAGNOSIS

Fig. 1.3 Exomphalos in an aborted fetus demonstrated on Fig. 1.4 Exomphalos in a fetus with trisomy 13. Doppler flow
postmortem babygram. It displays the relatively small size of is seen in the umbilical cord vessels (arrow).
the abdomen compared with the volume of bowel and liver
in the sac. This illustrates why return of the sac contents into
the abdominal cavity after birth can be difficult.

Fig. 1.5 Gastroschisis. Multiple loops of bowel have extruded Fig. 1.6 Antenatal scan at 16 weeks’ gestation showing trunk
through a defect in the anterior abdominal wall. and umbilical cord (arrow) with bowel loops protruding just to
the right of the attachment of the umbilical cord.

Liver

Bowel

Stomach

Fig. 1.7 Colour Doppler ultrasound scan in a Fig. 1.8 Gastroschisis. Transverse abdominal ultrasound scan
32-week gestation fetus with gastroschisis showing blood of a 19-week gestation fetus showing stomach and liver in
flow in the extra-abdominal mesenteric vessels. the abdomen and extruded bowel.

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 ANTENATAL DIAGNOSIS 3

Liver

Fig. 1.9 A giant exomphalos containing the liver in a Fig. 1.10 Scan at 24 weeks’ gestation showing a congenital
16-week gestation fetus. Note the size of the exomphalos in diaphragmatic hernia with a fluid-filled cavity (stomach, ST)
comparison to the abdominal circumference. beside the heart (HRT).

Fig. 1.11 Left-sided diaphragmatic hernia. Longitudinal scan

of thorax showing a fluid-filled stomach in the thorax.

Left

Stomach

10
Heart

Fig. 1.12 Antenatal scan at 29 weeks’ gestation showing Fig. 1.13 First postnatal chest radiograph of the same infant
a fluid-filled stomach beside the heart in a left-sided as in Fig. 1.12 confirming the diagnosis of a left-sided
diaphragmatic hernia. congenital diaphragmatic hernia.

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 4 ANTENATAL DIAGNOSIS

Fig. 1.14 4D ultrasound scan showing a cervical lymphatic Fig. 1.15 EXIT procedure on the same infant with a cervical
malformation. This baby was delivered by the ex-utero mass lesion.
intrapartum treatment (EXIT) procedure.

Fig. 1.17 Multicystic lymphatic malformation in the neck of

a fetus (arrow) seen on ultrasound scan.

Fig. 1.16 A large cervical teratoma on antenatal MRI.

Fig. 1.18 Unilateral cleft lip and palate on 3D ultrasound scan.

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 ANTENATAL DIAGNOSIS 5

Fig. 1.19 Same fetus as in Fig. 1.18 on 2D ultrasound Fig. 1.20 Colour Doppler scan at 30 weeks’ gestation
scanning showing the cleft lip and palate. showing an intra-abdominal fluid-filled cavity separate from
the bladder, consistent with a duplication cyst.

Fig. 1.21 Scan of the trunk at the level of the liver at

32 weeks’ gestation, showing no stomach within the
abdomen. If there is a small or absent stomach, particularly
with polyhydramnios, oesophageal atresia is a possibility.

(B)
Figs. 1.22A, B (A) Antenatal ultrasound scan through the
trunk showing showing two fluid-filled cavities in the upper
abdomen, consistent with duodenal atresia. (B) Same baby
(A) at 3 hours after birth with classic double bubble on x-ray.

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 6 ANTENATAL DIAGNOSIS

Fig. 1.23 Scan at 28 weeks’ gestation showing a double- Fig. 1.24 Coronal scan of a fetus at 18 weeks showing
bubble sign in another fetus with duodenal atresia. echogenic bowel. Echogenic bowel may be seen in
otherwise normal fetuses but can also be a marker for cystic
fibrosis, intrauterine viral infection and aneuploidy.

Fig. 1.25 Antenatal scan showing echogenic masses in the Fig. 1.26 Large multicystic ovary in a fetus at 34 weeks’
liver view, consistent with fetal gallstones or biliary sludge. gestation. Early postnatal follow-up is required.

Stomach

Fig. 1.27 Transverse ultrasound scan of the upper abdomen Fig. 1.28 Congenital pulmonary airway malformation
at 14 weeks’ gestation showing a hepatic cyst. (CPAM) involving the right lower lobe in a 30-week gestation
fetus on transverse section.

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 ANTENATAL DIAGNOSIS 7

Fig. 1.29 CPAM in the right lower lobe on a longitudinal Fig. 1.30 Likely extralobar pulmonary sequestration as
ultrasound scan of the fetus. evident by the large vessel running directly off the aorta.

Fig. 1.31 The fetal thymus is a large structure, here exposed Fig. 1.32 Hemivertebrae (arrow) visible on a 28-week
after removal of the left chest wall. The phrenic nerve can be antenatal ultrasound scan.
seen running behind it, over the surface of the pericardium.

(A) (B)
Figs. 1.33A, B (A) Ultrasound scan at 20 weeks’ gestation showing both feet, with a normal right foot and club foot on the
left. (B) 3D reconstruction of the same fetus at 24 weeks clearly showing bilateral talipes equinovarus.

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 8 ANTENATAL DIAGNOSIS

Head
Fig. 1.34 Twelve-week’ gestation ultrasound scan showing Fig. 1.35 Spina bifida was diagnosed in this fetus at
the head and face of a fetus with anencephaly. 18 weeks’ gestation. The lemon-shaped head is evident on
ultrasonography.

Fig. 1.36 Posterior view of the fetal skull showing Fig. 1.37 Spina bifida of the lumbosacral spine on an
dilatation of the posterior horns of the lateral ventricles antenatal scan showing an obvious gap in the dorsal arches
in hydrocephalus. (between the + markers).

Fig. 1.38 Spina bifida showing a lumbosacral defect, which Fig. 1.39 Transverse scan of the trunk at 30 weeks’ gestation
is probably myelomeningocele filled with cerebrospinal showing the myelomeningocele containing CSF (arrow).
fluid (CSF).

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 ANTENATAL DIAGNOSIS 9

Fig. 1.40 Ultrasound scan at 28 weeks’ gestation showing a Fig. 1.41 Pelvicalyceal dilatation in the left kidney evident at
duplex right kidney. 28 weeks’ gestation.

Fig. 1.42 Transverse scan of a 32-week fetus showing

bilateral dilatation of the renal pelves. In this fetus posterior
urethral valves must be considered and the gender, posterior
urethra, thickness of the bladder wall and whether the
bladder is emptying normally must also be evaluated.

Fig. 1.43 Keyhole sign on an 18-week gestation ultrasound

scan showing dilatation of both bladder and posterior
urethra, consistent with a diagnosis of posterior urethral
valves.

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 10 ANTENATAL DIAGNOSIS

Fig. 1.44 Duplex left kidney with dilatation of the lower pole Fig. 1.45 Colour Doppler scan at 28 weeks’ gestation
moiety. showing both kidneys with some dilatation of the left
kidney and multiple cysts in the right kidney, suggestive of a
multicystic dysplastic kidney.

Fig. 1.46 Longitudinal view of the trunk showing Fig. 1.47 Scan of the fetal pelvis showing a dilated bladder
hydroureteronephrosis and a full bladder in a fetus with with a large ureterocele, which may prolapse into and block
posterior urethral valves. the urethra.

Fig. 1.48 The fetal adrenal is almost the same size as the
fetal kidney. In this 16-week fetus, sectioned at the mid-
abdominal level, the right adrenal dominates the right
kidney on which it sits.

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 CHAPTER
Major neonatal conditions
2
Most major conditions in the neonate that require surgical EXSTROPHY
correction are congenital, but a few (e.g. neonatal necrotis-
ing enterocolitis and pulmonary interstitial emphysema) are Bladder exstrophy and cloacal exstrophy are major congenital
acquired. They often have external manifestations and are abnormalities involving failure of the lower abdominal wall
obvious at birth (e.g. gastroschisis and imperforate anus) to close, exposing the mucosal surface of the bladder. Other
or cause functional disturbance, which enables them to be features may include exomphalos, pubic diastasis, deficient
diagnosed within the first few days (e.g. severe respiratory urethra, unfused genitalia and rectal prolapse.
insufficiency in congenital diaphragmatic hernia and bilious
vomiting in duodenal atresia). PRUNE BELLY SYNDROME
The infant, usually a boy, is born with a flat and wrinkled-­
VENTRAL ABDOMINAL WALL DEFECTS looking abdomen and undescended testes. Prune belly syn-
The two most common major ventral abdominal wall defects drome may be due to transient intrauterine obstruction of
are exomphalos and gastroschisis. In exomphalos, there is urinary outflow, causing gross distension of the bladder and
a large defect at the umbilicus with protrusion of abdomi- upper urinary tract, which in turn is the cause of abdomi-
nal viscera into a thin membranous sac, which is formed by nal distension. Another theory is that the condition is due to
amniotic membrane on the outside and peritoneum on the abnormal mesodermal development.
inside. In the vast majority of infants, the sac is intact irre- Following spontaneous relief of obstruction, the stretched
spective of the mode of delivery (vaginal delivery versus cae- and attenuated ventral abdominal wall looks shrivelled and
sarean section). At birth the contents, usually small bowel wrinkled (‘like a prune’) but the dilatation of the urinary
and liver, can be seen clearly through the translucent mem- tract persists, often for many years.
brane but as desiccation of the membrane occurs, it becomes
opaque. The size and shape of the defect vary considerably,
ANORECTAL MALFORMATIONS
and in very large defects (giant exomphalos), most of the
intra-abdominal viscera are within the sac, and the abdomen Anorectal malformations manifest as a range of appearances.
appears scaphoid and of small volume. The skin of the ventral In ‘low’ lesions in the male, a fistula communicates with the
abdominal wall extends up the side of the sac to a variable skin via an opening in the midline anterior to the ­normal
degree. The umbilical arteries and umbilical vein can be seen position of the anus, either in the perineum, scrotum or
traversing within the membrane, converging at the umbilical ventral midline of the penis. ‘High’ lesions frequently have
cord. Exomphalos is associated with other major congenital a communication with the urinary tract, most commonly
abnormalities, particularly cardiac, renal and chromosomal, through a rectourethral fistula, but occasionally directly into
in about 50% of cases. In Beckwith–Wiedemann syndrome, the bladder neck as a rectovesical ­fistula. ‘High’ anorectal
there is hemihypertrophy, macroglossia, visceromegaly and malformations may occur without any fistula; this variant is
abnormal facies. It is essential to detect and treat accompany- most commonly seen in Down syndrome.
ing hypoglycaemia. In the female, the number of external orifices in the
In gastroschisis, the actual defect in the ventral abdomi- perineum will give some indication of the level of the anom-
nal wall is much smaller, and nearly always lies immediately aly. Where there are three openings, namely urethral, vag-
to the right of the umbilicus. The umbilical vessels are unaf- inal and anal, the lesion is a ‘low’ one; when there are two
fected and are situated to the left of the protruding bowel. obvious openings, namely urethral and vaginal, it is a high
There is no covering membrane. Much of the bowel and, lesion; and when there is one opening, it is known as a cloacal
frequently, the stomach herniates through the defect and the abnormality. The exception to this general rule is in the case
bowel and mesentery may be thickened, congested and oede- of a rectovestibular fistula, which may have the same external
matous with an overlying fibrin ‘peel’. Gangrene of the herni- appearance as an anovestibular fistula. The clinical distinc-
ated bowel may occur if the blood supply is occluded by the tion can be made according to the direction in which a probe
narrow opening or as a result of volvulus. Where this process runs. In the former, it will tend to run deeply parallel to the
has occurred well before birth, the necrotic bowel is resorbed, vagina, whereas in the latter, it will run first in a posterior
leaving an atresia. In gastroschisis, extraintestinal abnormal- direction in a subcutaneous plane, before it turns deeply at
ities are uncommon. the level of the anus.

11

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 12 MAJOR NEONATAL CONDITIONS

A fistula opening on the perineal skin is easily identified or female. In the commonest autosomal recessive variety,
when it transmits meconium or air, but the opening can be deficiency of the adrenocortical enzyme 21-­ hydroxylase
tiny and requires a careful search with magnification and causes low cortisol levels and a compensatory increase in
good illumination. In high lesions in males, the presence of secretion of pituitary adrenocorticotrophic hormone, result-
a rectourethral or rectovesical fistula can be inferred if air or ing in adrenal hyperplasia. The excessive androgens produced
meconium is passed per urethram. The fistula is usually con- in females cause virilisation of the external genitalia but
firmed by subsequent contrast studies (distal loopogram and the internal anatomy is normal for a female. Investigations
cystourethrography), which show ‘beaking’ of the terminal include estimation of serum electrolytes and blood glucose
rectum where the contrast enters the urinary tract. (to detect hyponatraemia, hyperkalaemia and hypoglycae-
The use of an ‘invertogram’ (or shoot-through lateral mia), serum 17-hydroxyprogesterone and urinary pregnane-
radiograph of the pelvis with the baby prone) at 12–24 hours triol. Chromosomal analysis is mandatory and screening for
of age, once gas reaches the distal bowel, may provide addi- the known genes involved in sex development is becoming
tional information on the level of the abnormality. The radio- more common. A urogenital sinogram or urethroscopy will
graph is taken in an exact lateral projection with the baby show a masculinised urethra and the presence of a vagina and
being placed prone over a padded wedge. Gas rises to the cervix. A pelvic ultrasound confirms the presence of a uterus,
apex of the blind-ending rectum, and the level is related to Fallopian tubes and ovaries.
various skeletal landmarks corresponding to the levator sling. Some infants are born with normal male chromosomes
There is less reliance on plain radiographs these days to deter- and testes but with insensitivity to androgens. A genetic
mine the level of the anorectal malformation because clinical abnormality in the androgen receptor system prevents the
examination with or without a perineal ultrasound scan is normal target tissues for androgens (Wolffian ducts and exter-
often sufficient. nal genitalia) from responding to androgen stimulation. The
Neonates with an anorectal malformation require inves- abnormality may be partial or complete. In the complete form
tigation for associated anomalies: an ultrasound scan of the (complete androgen insensitivity syndrome, CAIS), the exter-
­urinary tract and spine and radiographs of the chest and spine. nal genitalia are completely female in appearance. The clue to
Some also need an echocardiogram and/or ­ karyotyping. the gonads being testes in a phenotypic female is their discov-
Those with ‘high’ lesions usually require management with ery in inguinal herniae. The normal secretion and response
a temporary diverting stoma and are further investigated at a to anti-Müllerian hormone (AMH) leads to regression of the
later date by contrast studies ± endoscopy. Müllerian ducts, while failure to respond to androgens pre-
vents the development of a vas deferens.
Disorders of sex development may be produced by dyspla-
AMBIGUOUS GENITALIA (DISORDERS OF sia of one or both testes. When both testes are dysplastic, defi-
ciency of androgen may cause incomplete virilisation, and
SEXUAL DEVELOPMENT [DSD]) deficiency of AMH may allow persistence of Müllerian duct
Genitalia are considered ambiguous when one or more of the structures. Usually, both testes are undescended because they
following features are present: are unable to secrete enough hormones to enable testicular
descent. In the asymmetrical form of dysplastic testes (mixed
1 The phallus is too large for a clitoris or too small for a gonadal dysgenesis), one gonad may be a testis that has
penis. descended with preservation of the ipsilateral Wolffian duct
2 The urethral opening is proximal, near the labioscrotal and local regression of the Müllerian duct. The more dysplas-
(genital) folds. tic testis usually remains in the abdomen and has failed to
3 The genital folds remain unfused, giving the appearance of cause regression of the Müllerian duct or preservation of the
labia or of a cleft scrotum. Wolffian duct. Infants with mixed gonadal dysgenesis may
4 The testes are either not descended or impalpable. appear to be males with severe hypospadias and one palpable
testis. These dysplastic testes have an increased risk of malig-
There is variation in the degree of abnormality that may nant degeneration.
be present, making gender assignment at birth hazardous. In severe hypospadias with undescended testes the phallus
Prompt and accurate diagnosis is imperative because of may be large enough to indicate that the infant is essentially
the social implications for the parents of not being able to male, and usually the chromosomal karyotype is normal
announce the gender of the baby, and the malformation may male (46, XY). A contrast urethrogram will demonstrate a
be the outward sign of the life-threatening condition congen- normal male urethra without a vagina or uterus. The testes
ital adrenal hyperplasia. When congenital adrenal hyperpla- may be impalpable (in the inguinal canal or abdomen) or pal-
sia occurs in females, the appearance of the external genitalia pable near the pubic tubercle, on one or both sides. Severe
may cover a broad spectrum, suggestive more of either male hypospadias with undescended testes has to be distinguished

K31261_Book.indb 12 4/16/18 4:49 PM

 Another Random Document on
Scribd Without Any Related Topics
AKTIWITEIT 1

OM NA ‘N INFORMATIEWE TEKS TE LUISTER EN DIE INLIGTING

OP GEPASTE MANIER TE GEBRUIK

[LU 1.5]

a) Kom ons lees oor nog ‘n arend. Luister en volg eers terwyl jou opvoeder
die volgende teks aan julle voorlees.

Dokter Anton Rupert

Op 18 Januarie 2006 is dr. Anton Rupert rustig in sy slaap in sy huis op

Stellenbosch oorlede. Hy was 89 jaar oud.

Wyle Anton Rupert was ‘n groot Suid-Afrikaner en entrepreneur – een van

die grootstes wat ons land nog opgelewer het. Hy was nie net in Suid-Afrika
bekend nie, maar eintlik dwarsoor die wêreld. Hy was nie net ‘n baie ryk
sakeman nie, maar het ook op ander gebiede uitgestyg as ‘n leier. Ons
onthou hom ook as bewaarder en beskermer van die kunste en van ons
natuurlike omgewing.

Dr. Rupert is op 4 Oktober 1916 op Graaff-Reinet gebore. Hy het altyd gesê

die Karoo leer ‘n mens om nederig te wees, veral as jy daar na die sterre kyk.
Hy het daar skool gegaan en toe aan die Universiteit van Pretoria gaan
studeer. Hy wou eers ‘n mediese dokter word, maar kon nie die kursus
bekostig nie en het toe maar ‘n graadkursus in die wetenskap geloop. Daar
het hy ook vir Huberte Goote ontmoet – die vrou met wie hy 64 jaar lank
getroud sou wees. (Mevrou Rupert is in 2005 oorlede, slegs ‘n paar maande
voor dr. Rupert).

Hy het alreeds in 1957 ‘n aantal beginsels vir Afrikaanse besighede neergelê.

Drie daarvan was die volgende:

EERLIKHEID – omdat eerlikheid altyd die langste duur.

DIENS – altyd: aan jou kliënt, jou medemens en jou volk.

GELOOF – dat alles goed sal gaan as elkeen sy plig doen.

As gevolg van sy suksesse in die sakewêreld het hy een van die rykste mense
in die wêreld geword. Hy het die Rembrandt-tabakmaatskappy met slegs
R20 begin en dit tot ‘n reusebesigheid uitgebou. Later het hy ook Rothmans
International in Europa gevestig, en nog later ook Richemont gestig.
Laasgenoemde is ‘n maatskappy wat ander maatskappye besit, soos Dunhill,
Mont Blanc en Cartier, wat luukse goedere soos juwele verkoop. Sy
Richemont-besigheid is ongeveer R128 miljard werd!

In die laaste jare van sy lewe het hy amper al sy tyd gewy aan sy ideaal om
‘n netwerk oorgrensparke tussen lande in Suider-Afrika te vestig. Dit moes
toerisme bevorder en werk skep vir werklose mense. Daarom het hy in 1997
die Stigting vir Vredesparke saam met oudpresident Nelson Mandela en
wyle prins Bernard van Nederland begin. Behalwe sy bewaringswerk in
Suider-Afrika, het hy ook daarmee gehelp in Europa, Suid-Amerika en
Suidoos-Asië. Verder het hy in die 1960’s gesorg dat gratis mediese dienste
vir 25 jaar lank aan die mense van Lesotho gelewer word.

Baie van ons historiese geboue is deur sy toedoen gered, soos die
vissershuisies van Kassiesbaai op Waenhuiskrans, die Van Wouw-
huismuseum in Pretoria, die Reinethuis en die Drostdy-hotel op Graaff-
Reinet, die wit huise in die middedorp van Stellenbosch, die Bo-Kaap-
museum en talle, talle meer.

Hy en sy vrou was ook entoesiastiese versamelaars van kunswerke. Baie

daarvan is te sien in die Rupert-museum op Stellenbosch.

Bewaarder van die land se historiese geboue, kunsskatte, die natuurerfenis

en diereryk; bevorderaar van kleinsake as die groot skepper van
werkgeleenthede; weldoener wat ander gehelp het om hulleself te help –
noem maar op.

Arm begin. Skatryk geword. Wêreldwyd bekend. Beroemd. Gerespekteer.

Onder sy vriende het talle koninklikes en staatshoofde getel. Maar dié wat
hom geken het, sal hom onthou as iemand wat altyd nederig gebly het.
BRONNE: Gedenkbylae by Die Burger, Januarie 2006.

Die Kerkbode, 10 Februarie 2006.

AKTIWITEIT 2

OM ‘N VERSKEIDENHEID LEES- EN BEGRIPSTRATEGIEË TOE TE

PAS

[LU 3.1.2]

b) Gebruik die leesstuk om in julle groepe hardop aan mekaar voor te lees.
Probeer veral om duidelik en vloeiend te lees en om die moeiliker woorde
korrek uit te spreek.

AKTIWITEIT 3

OM TE SOEKLEES VIR SPESIFIEKE BESONDERHEDE

[LU 3.1.1]

c) Gebruik nou die leesstuk om die antwoorde op die volgende vrae neer te
skryf:

In watter provinsie is Graaff-Reinet? (Jy kan ook jou atlas gebruik om te kyk
waar dié dorp is).

Wat het die Karoo vir dr. Rupert geleer?

Dink jy dr. Rupert was regtig ‘n groot Suid-Afrikaner? Gee minstens twee
redes vir jou antwoord.

Probeer jou bes om te skryf wat ‘n oorgrenspark is.

Wenk: breek die woord eers in lettergrepe op en dink goed daaroor voordat
jy die betekenis hier neerskryf.
v) Ons het gelees van wyle dr. Anton Rupert en wyle Prins Bernard. Wat
beteken dit as die woord “wyle” voor iemand se naam geskryf of gesê word?
As jy nie weet nie, sal jy dit op bladsy 1405 in die HAT vind.

As mens ‘n stuk skryfwerk van goeie gehalte wil doen, is dit nodig om dit
deeglik voor te berei. Jy moet jou gedagtes eers agtermekaar kry en dit selfs
met iemand anders bespreek. Jy moet ook moeite doen om die regte inligting
te kry. Op die volgende bladsye gaan julle so ‘n proses volg.

AKTIWITEIT 4

OM ‘N ONDERWERP TE KIES EN TE ONTLEED EN ‘N DINKSKRUM

OOR IDEES TE HOU

[LU 4.2.1]

Stap 1:

Julle opvoeder sal julle in klein groepe verdeel (liewer nie minder as drie in
‘n groep nie). Julle eerste taak is om julle onderwerp te kies, naamlik die
naam van ‘n Suid-Afrikaner wat julle as “ ‘n arend” beskou en oor wie julle
wil skryf. Elke groep moet ‘n ander “arend” kies. Elke groeplid moet
minstens een naam voorstel en redes gee waarom hy / sy die persoon
voorstel. Die groepie moet alle voorstelle bespreek en uiteindelik een naam
kies.

Wat is belangrik?

Die persone wat voorgestel word, moet Suid-Afrikaners wees.

Die persone kan van enige geslag of ras wees.

Die persone moet goeie rolmodelle wees.

Julle ouers mag julle vooraf help met name wat julle kan voorstel.

Wenk: Dink bv. aan Suid-Afrikaners wat presteer het in sport, politiek, die
vermaaklikheidswêreld, die mediese wetenskap of ander wetenskappe,
liefdadigheid, die versorging van mense, die kunste en musiek. Julle moet
egter seker maak dat julle meer as een bron van inligting oor die persoon kan
bekom.

AKTIWITEIT 5

OM INLIGTING ONDER VERSKILLENDE HOFIES TE

KATEGORISEER

[LU 5.3.3]

Stap 2:

Wanneer julle jul keuse gemaak het, moet julle besluit watter soort inligting
julle oor die persoon gaan soek, bv. kinderjare, opleiding, prestasies,
persoonlike eienskappe (soos Roland Schoeman se lojaliteit aan SA of dr.
Rupert se nederigheid). Maak daarvan aantekeninge sodat julle sal weet
waarna om te soek en uiteindelik ‘n inhoudsopgawe kan saamstel.

AKTIWITEIT 6

OM INLIGTING TE VERSAMEL EN TE KATEGORISEER

[LU 5.3.1]

Stap 3:

Elke groeplid bring die inligting (getik, geskryf, prente, knipsels, boeke,
sketse) wat hy / sy versamel het klas toe en deel dit met die ander groeplede
sodat almal oor dieselfde inligting beskik. Besluit sommer ook oor die
volgorde waarin julle die inligting gaan plaas en stel ‘n voorlopige
inhoudsopgawe op. Skryf dit onder mekaar neer.

Tot hier het jy saam met jou groeplede gewerk. Van nou af is jy eers weer op
jou eie.

AKTIWITEIT 7
OM ‘N KONSEPWEERGAWE TE SKRYF MET ‘N SENTRALE IDEE
EN GOED ONTWIKKELDE PARAGRAWE

[LU 4.2.3]

Stap 4:

Jy moet die inligting wat deur jou groeplede versamel is so deeglik bestudeer
dat dit vir jou voel asof jy die persoon self ken. Eers daarna kan jy begin
skryf. Jou eerste poging sal op los papier wees, sodat jy jou gedagtes goed
agtermekaar kan kry. Wanneer jy daarmee tevrede is, moet jy jou
konsepweergawe netjies op ‘n skoon vel papier of in jou werkboek
neerskryf, onder die opskrif: Inhoudsopgawe.

aktiwiteit 8

om jou skryfwerk te hersien deur te let op jou inhoud en taal en die

terugvoer van jou groeplede en opvoeder te gebruik

[lu 4.2.5]

Stap 5

Hersien jou werk deur dit self deeglik te lees. Gebruik jou woordeboek om
seker te maak dat jy spelfoute regstel en dat jy hoofletters en ander
leestekens reg gebruik het. Is jou inhoud korrek? Handel elke paragraaf oor
gedagtes wat bymekaar hoort?

AKTIWITEIT 9

OM JOU SKRYFWERK TE PROEFLEES EN DIE FINALE KONSEP TE

KORRIGEER

[LU 4.2.5]

Stap 6
In hierdie stap moet julle nou julle skryfwerk aan die ander groeplede wys.
Julle moet probeer om mekaar goeie raad te gee oor hoe julle jul werk kan
verbeter en watter foute julle nog kan uitskakel. Julle opvoeder kan ook
hiermee help. Skryf die verbeteringe in ‘n ander kleur as jou
konsepweergawe neer.

AKTIWITEIT 10

OM JOU WERKSTUK FINAAL OOR TE SKRYF EN OOR DIE

ASSESSERING DAARVAN TE DINK

[LU 4.2.5]

Stap 7

Dink ‘n gepaste naam vir jou werkstuk uit en skryf dit bo-aan. Dit word
gevolg deur jou inhoudsopgawe. Daarna skryf jy jou finale weergawe sodat
dit gereed kan wees vir assessering.

Taalstruktuur en -Gebruik

AKTIWITEIT 11

OM TE LEER DAT TALE WOORDE BY MEKAAR LEEN EN OM

NUUTSKEPPINGE TE GEBRUIK

[LU 6.1.11]

Ons land se inwoners het ‘n verskeidenheid moedertale. Julle moedertaal is

Afrikaans, maar daar is ook Suid-Afrikaners wat ‘n ander moedertaal het.
Kan julle dalk ‘n paar noem?

a) Leenwoorde

Tale “leen” dikwels woorde by mekaar. Afrikaans het ook woorde by ‘n

verskeidenheid ander tale geleen.

b) Nuutskeppinge
Afrikaans is ‘n taal wat “lewe” en “groei”, want daar word gedurig nuwe
woorde in ons taal bygevoeg. Die meeste van hierdie nuwe woorde kom uit
leerareas soos Tegnologie en Elektronika, omdat daar gedurig nuwe
ontwikkelinge en uitvindings is. Dink maar aan nuwe woorde wat ontstaan
het uit die uitvinding en ontwikkeling van die sellulêre foon en die digitale
kamera. Die volgende verrassende voorbeeld kom in die 2005-uitgawe van
die HAT (bladsy 1051) voor:

SMS: ‘n Stelsel waarvolgens selfoongebruikers boodskappe kan stuur en

ontvang.

“SMS” word dus reeds as ‘n nuwe woord in Afrikaans erken.

(i) Sulke nuwe woorde word nuutskeppinge of neologismes genoem. Die

volgende woorde is enkele voorbeelde van nuwe Afrikaanse woorde wat die
afgelope paar jaar geskep is. Slaan in ‘n verklarende woordeboek soos die
HAT na wat elkeen beteken.

Bemagtig:

Infrastruktuur (van ‘n land):

e-pos (HAT, p.220)

Vigs:

CD-ROM:

(ii) Probeer om sinne te maak waarin elk van die volgende nuutskeppinge se
betekenis duidelik is:

voëlgriep:

biep:

oorgrensparke (kom voor in leesstuk oor dr. Anton Rupert):

AKTIWITEIT 12
OM DIE VERSKILLENDE KOMPONENTE VAN SINNE
(ONDERWERP, VOORWERP, GESEGDE) UIT TE KEN EN TE
VERSTAAN

[LU 6.2.1]

Julle het alreeds in graad 4 kennis gemaak met die verskillende dele
(komponente) waaruit sinne bestaan, naamlik die onderwerp, gesegde en
voorwerp. Kom ons hersien dit gou.

Voorbeeldsin: Die kaptein vang die bal.

Om die komponente van ‘n sin uit te ken, is dit die maklikste om by die
gesegde te begin. Jy moet net onthou dat die gesegde die woord(e) in die sin
is wat aandui of die sin in die teenwoordige, verlede of toekomende tyd
geskryf is. Dit is dus gewoonlik ’n werkwoord (teenwoordige tyd), maar dit
word ook saam met ‘n hulpwerkwoord soos sal of het gebruik in die
toekomende en verlede tyd. Om die drie komponente uit te ken, moet jy drie
vrae vra.

Vraag 1: Wat is die gesegde in die voorbeeldsin hierbo? Dit is vang.

Vraag 2: Wie of wat vang? Die antwoord op die vraag is die onderwerp,
naamlik: Die kaptein.

Vraag 3: Wat vang hy? Die antwoord op die vraag is die voorwerp, naamlik:
die bal.

Die drie komponente van die sin is dus die volgende:

Onderwerp: Die kaptein

Gesegde: vang

Voorwerp: die bal.

Hier volg nou drie enkelvoudige sinne. Gebruik die voorbeeld hierbo om die
drie vrae korrek te vra sodat jy kan vasstel wat die onderwerp, gesegde en
voorwerp in elke sin is.

(a) Petro skryf ‘n brief.

Onderwerp:

Gesegde:

Voorwerp:

(b) Hy het die potlood opgetel.

Onderwerp:

Gesegde:

Voorwerp:

(c) Pappa sal my vanmiddag saamneem.

Onderwerp:

Gesegde:

Voorwerp:

Maak nou drie enkelvoudige sinne van jou eie – een in die teenwoordige,
een in die verlede en een in die toekomende tyd. Breek elke sin in sy
komponente op en dui so aan wat die onderwerp, gesegde en voorwerp in
elke sin is.

Sin 1 (Teenw. tyd):

Onderwerp:

Gesegde:

Voorwerp:
Sin 2 (Verlede tyd):

Onderwerp:

Gesegde:

Voorwerp:

Sin 3: (Toekomstige Tyd):

Onderwerp:

Gesegde:

Voorwerp:

AKTIWITEIT 13

OM SINNE UIT TE BREI DEUR DIE BYVOEGING VAN

BYVOEGLIKE NAAMWOORDE, BYWOORDE EN BYSINNE

[LU 6.2.3]

Jy praat nie altyd in kort, enkelvoudige sinne nie. Jou sinne is dikwels
langer, omdat jy woorde byvoeg wat beter beskryf wat jy eintlik wil sê. In
die volgende sinne is die skuinsgedrukte woorde bygevoeg om ‘n duideliker
beskrywing te gee.

Die vinnige atleet het die moeilike wedloop gewen.

(Twee byvoeglike naamwoorde)

Juffrou sê sy sal my later help. (Bywoord)

Die man wat baie haastig is, het vertrek. (Bysin)

(Jou opvoeder sal vir julle verduidelik wat ‘n bysin is).

Brei die volgende sinne uit met byvoegings soos gevra:

Die fotograaf neem _ foto’s. ( Byvoeglike naamwoord).

Mamma het _ ‘n koek gebak. (Bywoord).

Die _ dokter het vir my _ medisyne gegee. (Twee byvoeglike naamwoorde).

Die boom __, is baie hoog. (Bysin).

Dr. Rupert was ‘n _ (Byvoeglike naamwoord) man wat __. (Bysin).

My persoonlike woordelys

(GEBRUIK DIE VOLGENDE OPSKRIFTE)

Table 1.15.
Woord Opgebreek Kort sin

Assessering

LU 1

LUISTER

Die leerder is in staat om vir inligting en genot te luister en gepas en krities

binne ‘n wye verskeidenheid situasies te reageer.

Dit is duidelik wanneer die leerder:

1.5 luister na verskillende soorte informatiewe tekste (aanwysings,

instruksies, ens.), kennis neem van hoofidees of spesifieke besonderhede en
inligting op ‘n gepaste manier gebruik.

LU 3

LEES EN KYK
Die leerder is in staat om vir inligting en genot te lees en te kyk en krities op
die estetiese, kulturele en emosionele waardes in tekste te reageer.

Dit is duidelik wanneer die leerder:

3.1 ‘n verskeidenheid fiksie- en nie-fiksietekste vir verskillende doeleindes

lees:

lees onafhanklik deur ‘n verskeidenheid lees- en begripstrategieë gepas vir

verskillende doeleindes te gebruik:

soeklees vir spesifieke besonderhede;

3.1.1.5 maak voorspellings oor inhoud en slot;

3.1.2 voer luidlees duidelik uit en pas leesspoed volgens doel en gehoor aan.

LU 4

SKRYF

Die leerder is in staat om verskillende soorte feitelike en verbeeldingstekste

vir ‘n wye verskeidenheid doeleindes te skryf.

Dit is duidelik wanneer die leerder:

4.2 idees deur die skryfproses ontwikkel en organiseer:

4.2.1 kies en ontleed ‘n onderwerp en hou ‘n dinkskrum oor idees met

behulp van kopkaarte, vloeidiagramme en lyste;

4.2.2 ontwikkel die onderwerp deur relevante bronne te raadpleeg, gepaste

inligting te kies en idees te organiseer;

4.2.3 skryf ‘n konsep-/eerste weergawe met ‘n sentrale idee en goed

ontwikkelde paragrawe;
4.2.5 hersien werk deur op inhoud, gepaste taal, struktuur en styl te fokus en
terugvoering van klasmaats en onderwyser te gebruik;

4.2.6 proeflees en korrigeer finale konsep;

4.2.7 lewer finale weergawe in en besin oor die assessering van die stuk.

LU 5

DINK EN REDENEER

Die leerder is in staat om taal vir dink en redeneer te gebruik en inligting vir
leer te verkry, verwerk en gebruik.

Dit is duidelik wanneer die leerder:

5.2 taal gebruik om te ondersoek:

5.2.4 soek inligting in ander relevante bronne;

5.3 inligting verwerk:

5.3.1 versamel en kategoriseer relevante idees en verduidelik die redes vir

die kategorisering;

5.3.3 organiseer inligting onder verskillende hofies.

LU 6

TAALSTRUKTUUR EN -GEBRUIK

Die leerder ken en is in staat om die klanke, woordeskat en grammatika van

die taal te gebruik om tekste te skep en te interpreteer.

Dit is duidelik wanneer die leerder:

6.1 met woorde werk:

6.1.11 begryp dat tale woorde by mekaar leen en gebruik nuutskeppinge;

6.2 met sinne werk:

6.2.1 begryp dat sinne uit verskillende komponente bestaan (onderwerp,

voorwerp, gesegde) en verstaan die funksie van elk;

6.2.3 brei sinne uit deur adjektiewe, bywoorde, byvoeglike en bywoordelike

bepalings en bysinne by te voeg;

6.2.17 verstaan en gebruik gepaste sinonieme, antonieme, homonieme en

homofone;

6.4 bewustheid en gebruik van styl ontwikkel:

6.4.6 toon kennis van die gebruik van bekende idiomatiese uitdrukkings.

Memorandum

Aktiwiteit 1

a) Luisteroefening.

Aktiwiteit 2

b) Leesoefening.

Aktiwiteit 3

c) (i) Dis in die Oos-Kaap.

(ii) Die Karoo het hom geleer om nederig te wees.

(iii) Die leerders se antwoorde sal varieer.

(iv) oor-grens-park

Dis ‘n park wat oor verskillende lande se grense strek.

(v) Dit beteken dat die persoon alreeds oorlede is.

Aktiwiteite 4 – 10

Groep en individuele werk.

Taalstruktuur en -gebruik

Alle aktiwiteite wat betrekking het op Leeruitkoms 6 moet slegs as

voorbeelde beskou word. Dit word aanbeveel dat die opvoeder self meer
aktiwiteite / voorbeelde byvoeg, aangesien dié wat in die module voorkom
nie as noodwendig voldoende beskou behoort te word nie.

Aktiwiteit 11

a) Leenwoorde

b) Nuutskeppinge

(i) Bemagtiging: Om mag te gee aan iemand.

Infrastruktuur: Stelsels wat mekaar ondersteun sodat sake glad verloop, bv.
vervoer, gesondheidsdienste, bankwese, mynwese, ens.

e-pos: Briefwisseling met behulp van die internet.

vigs: Dodelike, hoogs aansteeklike siekte, deur ‘n virus oorgedra in die

bloed, gekenmerk deur ernstige verlies aan weerstand teen infeksie.

CD-ROM: ‘n Kompakte skyf in die rekenaar wat data vertoon wat slegs
gelees kan word en nie verander kan word nie.

(ii) Voëlgriep is ‘n siekte wat onder voëls voorkom en wat tans na al hoe
meer lande versprei.

Die selfoon het ‘n biepgeluid gemaak om aan te toon dat daar ‘n SMS is.

Die oorgrenspark tussen Suid-Afrika en Mosambiek is baie groot en baie

diere kom daarin voor.
Aktiwiteit 12

a) Onderwerp: Petro

Gesegde: skryf

Voorwerp: ‘n brief.

b) Onderwerp: Hy

Gesegde: het opgetel

Voorwerp: die potlood.

c) Onderwerp: Pappa

Gesegde: sal (vanmiddag) saamneem

Voorwerp: my.

Eie sinne.

Aktiwiteit 13

(a) mooi / interessante / duidelike / ens.

(b) gister / vanoggend / haastig / ens.

(c) vriendelike / slim / vreemde / goeie / ens.

lekker / slegte / ens.

(d) wat groen is, ens.

(e) ryk / slim / goeie / nederige

wat baie mense gehelp het.

Woorde, stories en ander taalsake*
AFRIKAANS HUISTAAL

Graad 5

SO MAAK MENS

Module 6

WOORDE, STORIES EN ANDER TAALSAKE

AKTIWITEIT 1

OM INLIGTING IN ‘N WOORDEBOEK NA TE SLAAN [LU 3.1.1]

OM SPELLING EN BETEKENIS IN ‘N WOORDEBOEK NA TE GAAN

[LU 6.1.6]

Gebruik ‘n verklarende woordeboek om die betekenis van die volgende

begrippe na te slaan. Skryf dit in die spasies wat daarvoor gelaat is.
 Figure 1.6.

AKTIWITEIT 2

OM NA ‘N STORIE TE LUISTER [LU 1.1]

OM TEKSTUELE LEIDRADE TE GEBRUIK OM AFLEIDINGS TE

MAAK

[LU 3.1.1]

OM DIE HOOFIDEE EN INTRIGE TE BESPREEK [LU 3.5.1]

OM AFLEIDINGS TE MAAK OOR DIE INTRIGE EN
HOOFKARAKTERS

[LU 3.5.2]

Luister eers hoe jou opvoeder die storie van Dommie en die goue gans
voorlees. Lees dit dan op jou eie en beantwoord daarna die vrae.

DIE GOUE GANS

‘n Man en vrou het drie seuns gehad. Die jongste se naam was Dommie,
want almal het gedink hy is maar dommerig. Almal by die huis het altyd met
hom gespot en hom verkleineer.

Die oudste seun het eendag besluit om te gaan hout kap in die woud. Sy ma
het vir hom ‘n heerlike pastei gebak en ook vir hom ‘n bottel goeie
koeldrank gegee sodat hy darem lekker kon eet as hy sou honger word van al
die harde werk. In die woud kom hy ‘n klein ou mannetjie teë en dié sê vir
hom: “Goeiedag, jong man. Gee asseblief vir my ‘n klein stukkie van jou
pastei en ‘n bietjie koeldrank uit jou bottel, want ek is baie honger en dors.”

Maar die slim jong man sê: “Ek vir jou van my vleis en koeldrank gee? Nee,
ek sal nie genoeg vir myself oorhê nie,” en hy stap verder.

Hy begin kap toe aan die eerste boom, maar die ou mannetjie het sy byl
getoor, want skielik gly die byl en hy kap sy been raak. Die wond was so
groot dat hy nie verder kon werk nie en hy moes dadelik huis toe gaan sodat
die wond verbind kon word.

Die tweede seun besluit toe om te gaan hout kap in die bos. Sy ma gee vir
hom ook ‘n heerlike pastei en ‘n bottel koeldrank vir sy middagete. Hy
ontmoet dieselfde mannetjie langs die pad, met dieselfde versoek: “Gee my
asseblief so ‘n ietsie van jou pastei en koeldrank, want ek is honger en dors.”

Hierdie seun het ook gedink hy is slim, want hy sê: “Hoe meer jy eet, hoe
minder is daar vir my. Gaan weg!”
Die ou mannetjie het ook sy byl getoor, want toe hy die tweede hou daarmee
kap, kap hy ook sy been raak. Hy moes ook huis toe gaan om die wond te
laat behandel.

Dommie sê toe vir sy pa: “Pa, ek wil ook graag gaan hout kap.” Maar sy pa
antwoord: “Jou twee broers het hulleself beseer. Jy moet maar liewer by die
huis bly, want jy weet tog niks van houtkap af nie.” Maar Dommie hou aan
neul en uiteindelik stem sy pa in: “Nou goed dan; gaan tog maar, maar jy sal
gou jou les leer.” Sy ma gee toe vir hom ’n ou stuk droë brood en ‘n bottel
suur bier en so is hy daar weg.

In die bos ontmoet hy dieselfde ou mannetjie wat vra: “Kan ek asseblief van
jou pastei en koeldrank kry? Ek is baie honger en dors.”

Dommie sê: “Ek het net ou droë brood en suur bier, maar as jy dit wil hê,
kan ons saam daaraan eet en drink.” Hulle gaan sit op die gras en toe
Dommie sy ou brood uithaal, sien hy dat dit in die heerlikste pastei verander
het. Tot sy verbasing het ook sy suur bier in die lekkerste koeldrank
verander. Hulle het lekker geëet en gedrink en toe hulle klaar is, sê die
mannetjie: “Omdat jy so goedhartig is en gewillig was om alles met my te
deel, sal ek iets goeds vir jou doen. Sien jy daardie ou boom? Kap dit af en
jy sal iets daaronder vind.” Toe stap hy weg.

Dommie het dadelik begin kap en toe die boom val, kry hy ‘n gans met goue
vere onder die boom!

(Word vervolg)

(Die Broers Grimm: Die Goue Gans)

Watter eienskappe was waar van Dommie se twee broers?

Table 1.16.
Ja Nee
Goeie maniere
 Eerbied
Respek
Selfsugtigheid

Dink jy Dommie se ma was goed vir hom? Gee redes vir jou antwoord.

Wat dink jy van Dommie se optrede teenoor die ou man? Was hy . . .

Table 1.17.
Ja Nee
vriendelik?
mededeelsaam?
selfsugtig?
goedgemanierd?

Watter les dink jy kan ons uit hierdie eerste gedeelte van die storie leer?

Wat dink jy daarvan dat hulle die jongste broer Dommie genoem het?

AKTIWITEIT 3

OM HARDOP TE LEES EN LEESSPOED AAN TE PAS

[LU 3.1.2]

Oefen tuis om die storie hardop te lees. Gee veral aandag aan vlotheid en
duidelike uitspraak. Probeer ook om jou stem reg te gebruik in die dialoog-
gedeeltes, dit wil sê waar mense met mekaar praat. Kom lees dit dan in julle
groepe hardop aan mekaar voor. Jou opvoeder kan dalk ook versoek dat jy
dit aan die klas voorlees. Wees dus gereed daarvoor!
AKTIWITEIT 4

OM DISKRIMINERENDE TAALGEBRUIK TE IDENTIFISEER EN TE

BEVRAAGTEKEN [LU 2.4.4]

OM STEREOTIPES TE HERKEN EN TE BESPREEK, ASOOK HOE DIT

GESKEP WORD [LU 3.8.2]

OM WOORDASSOSIASIES EN KONSEPTE TE ONDERSOEK EN UIT

‘N ANDER HOEK NA ONDERWERPE TE KYK [LU 5.4.5]

Bespreek in julle groepe wat julle van die jongste seun se bynaam dink. Gee
veral aandag aan die volgende:

a) Dink julle sy ouers het reg opgetree oor die benaming “Dommie”?

b) Watter mooi of aanvaarbare byname ken julle? Skryf dit neer. Dink aan
voorbeelde onder sportsterre, soos “Vinnige Fanie” (krieket), “Rocky”
(boks), “Super Sarel” (tydrenne), “Pistol Pete” (tennis), ensovoorts.

c) Wat is julle groep se standpunt oor benaminge wat op ‘n negatiewe en

diskriminerende manier verwys na mense se ras, geslag of gestremdhede?

AKTIWITEIT 5

OM GEVOLGTREKKINGS TE MAAK EN REDES DAARVOOR TE

GEE

[LU 5.3.6]

Skryf nou ‘n paragraaf oor elk van die volgende:

Paragraaf 1

Ons groep se mening oor diskriminerende naamgewing

Paragraaf 2
Ek dink name kan mense seer maak

Taalstruktuur en -Gebruik

Woordsoorte

In hierdie module gaan ons vier verskillende soorte woorde probeer uitken.
Hulle is

die selfstandige naamwoord (s.nw.)

die byvoeglike naamwoord (b.nw.)

die werkwoord (ww.)

die bywoord (bw.)

Die Selfstandige Naamwoord

Wat is selfstandige naamwoorde?

Dit is woorde wat een of meer van die volgende eienskappe besit:

‘n verkleiningsvorm,

soos gans – gansie

‘n enkelvoud en meervoud,

soos gans – ganse

woordjies soos ‘n en die kan ook altyd sinvol voor ‘n selfstandige

naamwoord gebruik word,

soos ‘n gans of die gans;

‘n veer of die veer.

AKTIWITEIT 6
OM SELFSTANDIGE NAAMWOORDE TE IDENTIFISEER

[LU 6.2.11]

a) In elkeen van die vier sinne wat volg, is daar ‘n selfstandige naamwoord.
Kan jy hulle uitken? Skryf hulle neer en skryf ook die rede waarom jy sê dis
‘n selfstandige naamwoord, byvoorbeeld:

Hy tel die gans op.

gans: dit word voorafgegaan deur die.

Sy het vir hom ou brood gegee.

Hy het ‘n bottel saamgeneem.

Sy wou net van sy vere pluk.

DIe prinses het lekker gelag.

b) Probeer ook om die selfstandige naamwoorde in die volgende leesstuk te

vind. Merk hulle met ‘n kleur van jou keuse.

Ganse is “waghonde”

Ganse word beskou as uitstekende wagters in die nag. Sommige boere hou
ganse op die plaas aan en maak vir hulle slaapplek naby die kraal waar die
vee snags slaap. Indien daar ‘n bedreiging gedurende die nag is, is die ganse
altyd die eerste om dit agter te kom en hulle maak dan dadelik ‘n groot
lawaai. Sodoende word die boer gewaarsku en kan hy sy eiendom,
byvoorbeeld klein lammertjies, beskerm.

Wanneer ons praat, sukkel ons gewoonlik nie met verkleinwoorde en

meervoude nie. Omdat ons Afrikaanssprekers is, weet ons amper instinktief
wat die korrekte gebruik van verkleinwoorde en meervoude is. Die uitdaging
is om dit korrek te spel! Kom ons leer ‘n paar dinge oor ons eie taal.

Verkleinwoorde
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