Chemo-/Strahlentherapie Anhang


[Olaf Posdzech]

Zusammenfassung des Übersetzers:

Eine Auswertung der Daten von über 200.000 Krebspatienten in den USA und Australien (im Zeitraum 1990 bis 2004) ergab ein katastrophales Ergebnis für die Chemotherapie: Es wurden 72.946 Krebspatienten

in Australien und 154.971 Krebspatienten in den Vereinigten Staaten untersucht. Man stellte fest, dass Chemotherapie insgesamt nur bei 2,3 (Australien) bzw. 2,1% (USA) aller Krebs-Patienten einen Erfolg brachte

(Erfolg = 5 Jahre Überlebenszeit). Dabei lag die Erfolgsrate bei den positiv ansprechenden Krebsarten bei 10 … 41%, bei den anderen jedoch unter 1,5%, häufig sogar bei Null,+clinical+oncology+16,+2004,+Australia&spell=1


[Elaine Lewis]

Cadm-s.: An important remedy in cancer treatment (patients who undergo Chemotherapy and Radiation)!  Give Cadm-s. right before treatments and again after as needed for the horrendous side effects.  Cadm-s. a cancer remedy in general (stomach cancer).  It’s a remedy for toxic poisonings in general.  You can also give it for morning sickness in pregnancy. 

[Dr. Farokh Master]

Dealing with the side effects of chemotherapy has always been a major concern. Chemotherapy side effects can be debilitating and can make life very unpleasant.

The following are the common side effect observed in my practice.

1. Sore mouth

Many chemotherapy drugs can inflame the lining of the area of the mouth as well as the throat. At times ulcerations are seen other then just soreness of the mouth. Radiations delivered to the head and neck can irritate the lining and cause sores too. Chemotherapy and radiation to the salivary glands can make the mouth very dry thus making the sores more painful. Fungal infection like monilia can also cause soreness. A good oral hygiene has to be maintained in order to avoid mucositis.

A good oral hygiene includes daily brushing and flossing to reduce the plaque. Any dental work like cleaning, tooth extraction filling of the cavities should be done at least 2 weeks in advance of the chemotherapy so as to give enough time for the mouth to heal. Ill fitting dentures should be fixed or replaced. A blood count should be taken before any dental work in order to check the WBC and Platelet counts. Low counts of these cells may lead to infection and bleeding respectively.

Use a soft bristle toothbrush. Also if brushing by toothpaste is painful use a cotton swab.

Mouth infections are dangerous and one should look out for any fungal growth in the mouth, which should be promptly treated.

Nutrition- A high calorie, high protein diet which can include scramble egg, custard, milkshakes, gelatins, macaroni and cheese will help the sore mouth or tongue heal faster. Drinking lots of water will also hasten the healing process. Following should be avoided till the mouth sores heals

- Foodstuffs of extreme temperatures.

- Citrus fruits like lemons, oranges and tomatoes.

- Salty foods, dry crackers, chips, toast and hot, spicy food, which cause burning sensation.

- Alcoholic beverages and tobacco since both irritate the lining of the mouth.

2. Loss/change of sense of taste

Many chemotherapy drugs can change the sense of taste. Sweet things might taste sour and sour things taste sweet. Chewed meat may have a bitter taste because of the release of proteins in the mouth. Sometimes there is continuous metallic taste in the mouth after chemotherapy. To lessen the taste effects following things can be tried.

- If food and beverages taste bitter, add sweet food or honey to it.

- Avoid spicy, highly seasoned food instead have bland chicken or fish, eggs and mild cheese or tofu.

- Marinated meat, chicken and fish may taste better. One can make use of soy sauce, sweet and sour sauce, lemon juice, and wine for marinating.

3. Nausea and vomiting

Nausea and vomiting are both temporary side effects of chemotherapy and radiation. Many chemotherapy drugs and drug combination have the potential to causing nausea and vomiting. Getting

3 or 4 drugs at a time can make the reaction even worse. The dosage and the number of cycles also matter. Females, young people, previous history of motion sickness or morning sickness in pregnancy can increase the risk of nausea and vomiting during chemotherapy.

Some patients suffer from ANV i.e., Anticipatory nausea and vomiting wherein the patient starts getting nausea and vomiting not only after the chemotherapy but also before the therapy as a result

of conditioned reflex.

A person’s anxiety state and how he responds to stress and disease are all-important factors in setting up this psychological pattern.

Drugs like Cisplastin, doxorubicin, methotrexate, cyclophophamide have highest potential to cause nausea and vomiting. Drugs like 5- Fluorouracil, hydroxyurea, etoposide, chlorambucil rarely cause nausea and vomiting.

Avoid eating hot, spicy food or other dishes that might upset the stomach. Eating slowly can avoid gas development and heartburn. Try to avoid odour of the cooking food that may bring about nausea. The time of the day when the treatment is given can sometimes make a difference.

            4. Loss of appetite

It is one of the most common side effects of chemotherapy but it may also result from radiation therapy, stress and anxiety, depression and lastly from cancer itself. It is usually a temporary side effect lasting for 3 to 8 days.

- Stimulate the appetite by exercising for 5 or 10 min about a half-hour before the meal.

- Eat frequent, small meals and have snacks between meals that appeal to the senses.

- Add extra protein in the diet. Fortify milk by adding one cup of nonfat dry milk to each liter of whole milk. Use of nutritional supplements can be helpful.

5. Constipation

It means infrequent movements as well as collection of dry hard stools. If it persist it may lead to stool ‘impaction’ a very large hard stool with difficulty in passing. Constipation may also lead

to bloated feeling leading to decrease in the appetite. The discomfort and pressure of an impaction can especially aggravate patients with heart, respiratory, or gastrointestinal diseases.

CAUSES: Lack of exercise, emotional stress, and lack of high-fiber or bulk-forming foods in your diet. Chemotherapy drugs such as vincristine, vinorelbine, and vinblastine are often constipating. Also morphine and codeine, gastrointestinal anti-spasmodics, anti-depressents, diuretics, tranquillizers, sleeping pills, and calcium and aluminum based antacids.

Tips to prevent constipation:

- Eat high-fiber and bulky food like fresh fruits and vegetables, dried fruit, whole-grain breads and cereals, and bran. Raw fruits and vegetables, including lettuce, when the WBC count

is lower than 1,800.

- Drink plenty of fluids and avoid dehydration.

- Add bran to the diet gradually. Start with 2 teaspoons per day and gradually work upto 4 to 6 teaspoons per day. Sprinkle bran on cereal or add it to meat loaf, stews, pancakes, baked foods, and other dishes.

- Avoid refined foods such as white bread, starchy desserts, and candy. Also avoid chocolate, cheese and eggs since these can be constipating.

- Prunes contain natural laxative as well as fiber. Warmed prune juice and stewed prunes will be the most effective.

- Eat large breakfast with some type of hot beverage, tea, hot lemon water, or decaffeinated coffee.

Treating stool impaction: It develops when all f the stool doesn’t pass through the colon or the rectum. The stool gradually gets harder and harder as water is absorbed by the bowel. Then the stool gets larger and larger.

If it is not passed it ma cause partial obstruction of the bowel obstruction or cause irritation of the rectum or anus. Defecation may cause small fissures or tear in the anus. The treatment includes getting fluid into the bowels to soften the stool for easy defecation or removal. Sometimes enema and manual extraction of the stool by a physician is required.

6. Diarrhoea

It may be because chemotherapy, radiation therapy to the lower abdomen, malabsorption because of surgery to the bowel, or a bowel inflammation or infection. Some broad-spectrum antibiotics can cause diarrhea, and it might develop because of intolerance to milk.

Treatment: limit the diet to mostly liquids like fruit drink, ginger ale, water and weak tea. Hot and cold liquid foods tend to increase intestinal muscle contractions and make the diarrhoea worse, so they should be warm or at room temperature. Allow carbonated drinks to lose their fizz- stir with a spoon and drink them.

Gradually add foods low in roughage and bulk- steamed rice, bananas, mashed potatoes, dry toast and crackers. As the diarrhoea decreases low-residue diet should be included. Frequent small meals will be easier on the digestive tract.


- Fatty greasy and spicy food.

- Coffee, regular teas, and carbonated beverages containing caffeine.

- Citrus fruits

- Food high in bulk and fiber, such as bran, whole grains cereals and breads, popcorn, nuts, and raw vegetables and fruits except apples.

Lactose intolerance: A lactase deficiency can sometimes develop after intestinal surgery, radiation therapy to the lower abdomen, or chemotherapy. One may experience bloating, cramps in abdomen with diarrhoea.

Avoid: milk and milk products such as ice cream, cottage cheese and cheese, butter and sour cream.

Consume lactose free, non-fat milk solids. One can use buttermilk or yogurt because the lactose in them is already been processed and is digested.

7. Lymphedema

It is a swelling caused by the build up of lymph in the soft tissues- develops because of some blockage of lymphatic system.Mostly lymphedema in cancer patients results from scarring after the surgical removal of the lymph nodes or after the radiation. It usually involves areas next to large collections of lymph nodes in the axilla, pelvic region and groins. Swelling in the legs and arm develop on obstruction of the lymphatics.

People with chronic lymphedema are more susceptible to infections and local injuries, which results in more scarring and additional lymphedema. Cellulitis often develops after minor cuts or abrations. Lymphedema can be aggravated by poor protein intake that may result from loss of appetite, nausea and vomiting from chemotherapy. Decrease in the albumin of the blood also leads to leakage in to the tissues, which leads to additional arm and leg swelling.

It more commonly develops in patients-

1. Of breast cancer who have been treated after surgery with radiotherapy to the regional lymph nodes areas.

2. Malignant melanomas with lymph node dissection and/or radiation involving an extremity.

3. Prostrate cancer or gynaecologic cancers after surgery, with or without surgery.

4. Testicular cancer with lymph node dissection, with or without radiation.

5. Patients who have had several courses of radiation to axilla, shoulder, or groin, especially if surgery have been performed there to treat recurrent cancer.

Preventiong and controlling:

- Whenever possible keep the affected limb elevated.

- Clean and lubricate the skin daily with oil or skin cream.

- Try and avoid any injuries or infection in the affected limb, also avoid extreme hot and cold application on the swollen limb.

- Don’t use blood pressure cuffs on the affected limbs. Wear clothes of loose fitting to avoid constrictive pressure.

- Watch for the signs of infection-redness, pain, heat, swelling, fever.

8. Hair loss

Alopecia is the most visible side effects of chemotherapy and hence most upsetting. Chemotherapy drugs have an especially destructive effect on rapidly growing cells like hair and the cells lining your mouth and gastrointestinal tract. Drugs like Cytoxan, Adriamycin, and vincristine cause hair loss.One may not lose all the hair, it may just become thin or patchy. Hair loss may happen in the first cycle, but it may not happen until the second cycle. Patient may develop some scalp irritation, dermatitis, or scaling. The hair may almost always come back, it may take around 3 to 6 months. The new hair might have a slightly different texture, colour and curl. Hair loss due to radiation to skull or brain may cause total and permanent hair loss.

9. Allergic and dermatologic reactions:

Chemotherapy can cause several skin reactions:

- Vinorelbine may cause burning along the vein during injection.In some cases, blisters along the vein have been reported.

- Patients receiving tretinoin can experience redness, dryness, itching, and increased sensetivity to sunlight and hence should take extra precaution.

- ‘Hand-foot’ syndrome is a painful, redness, irritation and fissuration of the hands and soles seen with fluorouracil, capecitabine, and liposomal doxorubicin. Moisturize the affected parts.

10. Effects on fertility:

Alterations in the reproductive function are now recognized as a common complication of chemotherapy.Women may experience premature gonadal failure, menopause, sterility, and even osteoporosis.

Man may have low sperm count and infertility.

The major drugs that cause gonadal dysfunction are the alkylating agents such as cyclophasphomide, thiotepa, nitrogen mustard, and chlorambucil.

For patients in whom fertility is spared, the outcome of pregnancy has not shown a higher incidence of congenital anamolies, spontaneous abortion or neonatal mortality.

Chemotherapy can be safely given during the second and the third trimester of pregnancy. Methotraxate therapy should be avoided strictly during the 1st trimester. Both cyclophosphamide and doxorubicin can be safely given in any trimester of the pregnancy.

            11. Effects of heart:

Some chemotherapy drugs such as doxorubicin, daunorubicin, eprubicin and idarubicin, or radiation therapy to the chest can cause adverse reaction to the heart. Cardiac congestion, decrease exercise tolerance are generally seen with prolonged treatment.The physician should obtain ejection fraction and echocardiography before and also during the treatment of chemotherapy.In case of damage to the heart the drugs can be stopped or modified.


Radiation therapy:

[Farokh Master]

Most of the cancer patients need radiation therapy as a part of their overall treatment plan at some point in their illness. It is often recommended as a primary treatment, but can also be used along with chemotherapy or surgery.

Radiotherapy uses high-energy X-rays, electron beams, or radioactive isotopes to kill cancer cells without exceeding safe doses to normal tissue. It accomplishes its purpose by killing cancer cells through a process called ionization. Some cells die immediately after radiation because of direct effect, though most die because the radiation damages the chromosomes and DNA so much that they can no longer divide.

There are several technical ways of giving radiation. The most common way is by external radiation in which a radiation beam is directed at the tumor from a machine. Internal or systemic radiotherapy delivers radiation by giving a radioactive source intravenously or by injection, for e.g. intravenous radioactive iodine

or radioactive gold into abdominal cavity. With intracavitory radiotherapy, an applicator containing radiation seeds is placed in an organ such as uterus.

In interstitial radiotherapy, the sources are placed directly in the tumor. Radiation can also be administered during surgery in a technique termed intraoperative radiation therapy (IORT).

These methods are usually used in combination with external radiation.

Planning the therapy:

The Stimulation: If external radiation is going to be used, the first step is called stimulation, performed on a special x-ray machine built to resemble the machine that ultimately will be used. Certain contrast agents or probes may be used to aid in stimulation. It is done to make all the necessary measurements to fix the precise location of the tumor. Marks will be made on your skin with a colored ink to outline the target the radiation oncologist will be aiming for- the “radiation port”- which has to be the same everyday.

The dosage: The term used to measure in units the amount of radiation received is centigray (cGy), but since one gray equals 100 rads, the two terms are interchangeable.

Careful planning allows the radiation oncologist to deliver the maximum effective dose to the visible tumor and any invisible tumor cells that might be nearby while protecting the surrounding normal tissue as much as possible. Calculating a dosage figure that balances these two goals can be complex, since the size and stage of the tumor have to be taken into account and since different tissues tolerate different levels of radiation.

The liver will tolerate 3,000 cGY, the lung 2,000, and the kidney 1,800. Higher doses can be delivered to small parts of one of these organs, but if the entire organ is given higher doses than these, normal tissues can be harmed.

The oncologist prescribes the total dose necessary to destroy the tumor, and then calculates a daily dose over a specific period. This is called the fraction schedule. Throughout, the radiation oncologist works with a figure called the therapeutic ratio, defined as a comparison of the damage to the tumor cells compared with normal cells. The therapeutic ratio can be enhanced in a number of ways- by using altered time fraction schedules, careful treatment planning, selection of the optimum radiation energy for the specific problem, and by the use of experimental techniques such as high linear energy transfer (LET) radiation or chemical modifiers that either make the tumor cells more sensitive to radiation or better protect normal tissues.

The Number of Treatments: Radiation is usually given daily 5 days a week. That schedule can continue for two to eight weeks depending on the tumor, the kind of the treatment being used, and the dosage required.

The point of using multiple treatments instead of single treatment is to give normal cells a chance to recover and repair themselves.

The Delivery Method: The method to be used to deliver radiation is base on many factors, including the biology of the tumor involved, the possibility of the side effects or complications, the physical characteristics of the various sources of radiation, and how these different sources affect the body’s many different cells, tissues, and organ systems. The method can be divided into external and internal radiation.

Types of external radiation:

The delivery of the dosage from the source outside the body- can vary according to the photon energy of the machines involved, the type of beams produced (electrons, X rays, gamma rays), when the treatment is given, and the number of beams involved in the treatment procedure.

- High-and Low-Energy Radiation External beam treatment uses special equipment that uses either low energy (orthovoltage machines) or high energy

(megavoltage machines). All the machines used today are quite precise about where they deliver the radiation dose.

- Intraoperative Radiation Therapy (IORT) People with localized tumors that can’t be completely removed or have a high risk for local recurrence may be candidates for IORT, a treatment

carried out during surgery. The organ containing the tumor is localized and the surgeon removes as much of the tumor as possible. Then the normal tissue is moved out of the path of the

radiation beam. A treatment cone connected to a Linear Accelerator is placed directly over             the tumor, which is then treated with a single high dose. Normal tissues are spared, since they

are outside of the beam.

- Stereotaxic (Stereotactic) Radiosurgery also called as Gamma knife: Here a number of cobalt sources are used to treat deep-seated blood vessel malformations within the brain. Technical

information from the CT, MRIscan or angiogram is fed into treatment planning computer, and a dose distribution is calculated for the Linear Accelerator. The computer revolution and the

availability of Linear Accelerators have made this form of treatment (vascular malformation, meningiomas, acoustic neuromas, and some malignant brain tumors).

Types of internal (systemic) radiation therapy:

In this method of treatment, radiation to cancer cells delivered by being inserted directly into or around the tumor. Radioactive sources can be injected, housed in special applicators, or implanted in the form of needles or seeds.

Treatment with radioactive compounds: The use of radioactive tracers to treat tumors are unique in their ability to target specific tumors by being incorporated into their metabolism (e.g., thyroid cancer), finding antibody sites on tumor sites (e.g., lymphoma), localizing to tumor receptor sites (e.g., neuroendocrine tumors), or body’s own response to the tumor to deliver a treatment dose (e.g., strontium 89). The membrane of tumors may have specific antibody sites where antibodies (monoclonal antibodies) can react or may have nonspecific receptors (neuroendocrine tumors).

Interstitial radiation therapy: also called brachytherapy, places the sources of radiation directly in the tumor and surrounding structures. It’s most commonly used in tumors of the head and neck,

the prostate, and the breast.

It is also usually used in combination with external radiation. Intracavitary radiation: The most common use of this method is in gynecologic tumors, such as carcinoma of the uterus. Specially designed hollow applicators are placed in the uterus under general or spinal anesthesia. A small plastic tube containing the required number of sources of radioactive isotope of a specific strength are inserted into the hollow applicators. The sources and applicators are left in place for forty-eight to seventy-two hours. The seeds deliver the dose over the specified time, and once the dose is reached, the applicators and the sources are removed.

The advantage of this method is that a very high dose of radiation can be delivered to the tumor, while the rapid falloff in the dose gives maximum protection to the surrounding structures. Intraluminal radiation therapy: This method has limited use with some tumors in hollow organs like the esophagus and biliary tract.

In esophagus carcinoma, for example, a specially designed tube is placed into the opening (lumen) of the esophagus. Then under X-ray visualization-

fluoroscopy-several small radioactive sources are placed into the tube opposite the tumor. The tumor receives a high dose of radiation, while the dose to the surrounding structures is minimized.

            Side effects of radiotherapy:

The common side effects of radiotherapy are divided into Generalized(Systemic) and Local effects. The type of effect and how severe they become generally depends on the area treated, the size

of the radiation port, the daily dose rate, and the total dosage delivered. Not everyone taking radiotherapy suffers side effects.

1. Systemic Effects: One of the most common systemic side effects is fatigue or malaise. This is especially common among patients receiving treatments to large areas, such as the whole abdomen

and in total lymph node radiation. Nausea and vomiting may occur in patients receiving radiation to the upper abdomen, but it is rare in patients getting radiation to the head and neck, chest, or pelvis.

2. Localized Side Effects SKIN: Most skin reactions appear as redness called erythema. It is similar to sunburn and goes through the same stages- redness, gradual tanning, and then peeling. If the dose has been high, late skin changes may appear in the form of increased pigmentation.

Head and neck: The most significant side effect is irritation of the membrane lining or mucosa of the mouth- the mucous surrounding the tumor may become red. As the treatment progresses, quite

a few small superficial ulcers may develop. This can cause a lot of discomfort and will probably interfere with the swallowing and nutrition. The taste sensation may be affected if the tongue happens to be in the primary radiation beam. Also the amount of saliva produced can be significantly reduced if the salivary glands happen to be in the treatment beam.

Chest: The mucosal lining of the esophagus may get involved and the patient may develop heart-burn type symptoms.

Abdomen: Radiation to the upper abdomen can cause nausea and vomiting, usually during the first few days of treatment. As the treatment progresses the symptoms often diminished.

Pelvis: Treatment to the pelvis can bring about cramps, perhaps followed by diarrhea during the 2nd and 3rd week of treatment. Patient may have urine frequency, urgency to urinate or dysuria.

All these symptoms are temporary and will disappear soon after the treatment is completed.

Hair loss: Only hair within the radiation port will be affected by treatment. So a patient will loss his scalp hair only if he is receiving radiation to the head, usually for brain tumors. Whether the hair loss is temporary or permanent will depend on the dosage.


[Barbara Nowecki]

Ars.: Starke ängstliche, nervöse, innere Unruhe und Ruhelosigkeit.

Der Patient befindet sich in einem panikartigen Zustand und möchte fliehen. Er ist verzweifelt, schwach und frostig. Es besteht Übelkeit und Appetitlosigkeit.

Brennen im Magen mit Angst und Unruhe. Trotz des Brennens > Wärme und warme Auflagen.

Große Empfindlichkeit des Bauches gegen Berührung.

Er erbricht häufig und hat reiswasserähnliche Durchfälle, die schwächen.

Erbricht auch kleinste Mengen Wasser und Speisen. Das Erbrochene ist gelb wie Galle o. schwarz wie Kaffeesatz.

Übelkeit < Gerüche und Bewegung.

Verlangt: warme Getränken (Phos. kalte Getränke)

< nachts

Nux-v.: Das wichtigste Mittel zur Behandlung der Nebenwirkungen.

Übelkeit und Erbrechen während der Chemotherapie.

Erbrechen verschafft Linderung/erbricht sauren Schleim.

Die ganze Magenregion ist schmerzhaft aufgetrieben und es entwickeln sich krampfartige, schneidende Magenschmerzen.

Gefühl, er hätte Durchfall, meist aber finden wir eine hartnäckige Verstopfung.

Appetit fehlt und es besteht ein bitterer, fauliger Geschmack im Mund.

Sehr gereizt und leicht genervt.

Überempfindlich auf Gerüche, Geräusche, Licht, Musik.

Folge von Schmerzmitteln, die schon lange genommen werden.

Cadm-s.: Ähnlich wie Ars., aber Cadm-s. < Bewegung und nicht so unruhig.

Meist frostig, es gibt aber auch hitzige.

Starke Übelkeit, die ihn zwingt, ganz ruhig zu liegen, um Erbrechen zu vermeiden.

Verlangt nach kaltem Wasser, das sofort wieder erbrochen wird. Erbrochenes kann wie Kaffeesatz aussehen.

Beim aufstehen kann der Patient ohnmächtig werden.

Schläft mit offenen Augen.

Nicht allzu oft wiederholen.

Phos.: Schwache Menschen, die Angst vor dem Alleinsein haben.

Sie wünschen sich Trost und dass man ihre Hand hält. Sie fordern Trost auf eine liebevolle Art.

Das Wasser wird erbrochen, sobald es im Magen erwärmt wird.

Großer Durst auf kalte Getränke. Magenschmerz > kalte Getränke, Eiscreme, Massage, Handauflegen und Schlaf.

Das Erbrochene ist oft gelb oder grün wie Galle.

Unverdaute Teile im Stuhl, Schleimauflagerungen, fettige Stühle, blutig-schleimige Durchfälle, Bleistiftstuhl.

„Als ob keine Kontrolle mehr über den Schließmuskel“. „Als ob der Anus offen steht“.

Empfindlich auf Gerüche (Zigaretten und Parfüm)

Sulph.: Erbricht mit Hitzegefühl am ganzen Körper. Appetit vermehrt während der Chemotherapie.

Stark empfindlich auf Gerüche (eigene Stuhlgeruch und andere Ausscheidungen werden als übelkeitserregend empfunden).

Trotz schwieriger Lage macht er Scherze, erscheint hoffnungsvoll und ist optimistisch.

Tab.: Starke Übelkeit, verbunden mit Schwäche, Blässe, Erbrechen, eisiger Kälte, und Schweiß mit intermittierendem Puls.

Obwohl das Abdomen stark aufgetrieben und kalt ist, möchte er den Bauch nicht bedeckt haben.

Schwindel beim Öffnen der Augen.

Ip.: Starke Übelkeit mit erbrechen, unaufhörlich und schwallartig.

Das Erbrechen wird sehr leicht ausgelöst (Riechen von Speisen/hustend/bückend/nach Essen und Trinken/nach Stuhlgang/nach Kratzen der juckenden Haut).

Eingesunkene Augen.

Übelkeit im Magen bei sauberer Zunge.



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