La Crise Du Foie (cw: weight, weight loss, eating patterns)

"baby goat eating lubine" by freestocks.org CC0 1.0.

Just before Christmas, I snacked on homemade smoked mackerel pate on toast. I chased this down with too many Bendick mints and that night experienced one of the worst crise du foie attacks of my life. I have joined the ranks of those unable to tolerate the erratic and seasonal consumption of richer, fattier food, but it was not always so.

Despite its name, la crise du foie has nothing to do with the hepatic system or even gallstones, the food-lover’s curse. It has more to do with good old indigestion. La crise du foie is an invented expression beloved of the French and physiologically illiterate, yet it remains the singularly most expressive and elegant way to describe overindulgence and its consequences. (And certainly an improvement on the Anglo ‘bilious attack’ or ‘torpid liver’.) “La personne qui souffre d’une crise de foie va alors ressentir des vertiges, des nausées et d’autres maux gastriques. Cet état ne dure souvent que quelques heures ; et il se guérit spontanément après un peu de repos, accompagné d’une bonne hydratation et d’une absence de repas,” says one website, very Frenchly.

“Liver attack belongs to a vast nebula of representations and behaviours that are not only medical, where food, emotional, religious, sexual, clothing, climatic, colonial, national registers intersect, as well as those of power and emancipation,” writes Marie-Christine Pouchelle in the Journal of Ethnology for Europe, referring to it as an ‘heir to the hysterical crisis.’ Historically, many patients complaining of hepatic discomfort had their ovaries or uterus removed as part of their treatment. To this day, a person presenting with upper abdominal pain who conforms to the well-known (if sexist) clinical mnemonic 'fair, fat, female, fertile and forty' is considered likely to have cholelithiasis (although ‘familial’ has been suggested as a replacement for ‘forty’).

It is not hard to see how a female crise du foie might be pathologised as an unfeminine excess of appetite. Bile, wrote Diderot & d'Alembert, “ is a sulphurous menstruation capable of dissolving humors and exciting the walls of vessels.” The spasms in the gallbladder and colicky pains of indigestion were even equated with the contractions of labour. And unlike other overindulgences, the consequences of overeating tend to be written on the body. They are visible to all.

I have a single, large gallstone. Two years ago, while undergoing tests, I read about the three kinds of gallstones formed from either cholesterol, pigment, or a mixture of both. I was relieved to be told that mine was the latter, likely caused by rapid weight loss and, therefore, Less My Fault. I’m not fair, fertile, forty, or obese, but I am conscious of victim-blaming in medicine and how poorly-treated many patients are if they are seen as agents in their downfall. That humiliating mnemonic was uppermost in my mind as I lay on the examination couch and the blunt end of an ultrasound wand probed my torso. The dull pain felt like an admonishment I should accept as my due. I asked the sonographer if I might see the screen, and there it was, a dark blob wedged tight in the duct. It looked a bit like Barbapappa. “Even my gallstone looks corpulent,” I thought and then laughed at the deep irony of harming my health in pursuit of better health. “You have healthy, low blood pressure, and your harmful cholesterol levels are very low,” said the consultant in a consoling manner when I expressed shame at my diagnosis. I felt like I had been awarded a consolatory bronze star. Do a lot of people feel embarrassed at having gallstones? I asked. The ones who read up on it tend to, he replied. “Shame, guilt and embarrassment are harmful to one’s health.” Internalised weight stigma is real, as is the on-off dieting and restrictive eating that can cause gallstones to form. In these circumstances, our unhealthy reaction to appetite and weight gain is the problem, not the size of the body itself. In addition, it is possible to feel fatphobic about oneself and not about others. It’s complicated.

When I first started to research this newsletter, I posted a press query asking to speak to people working in the field of gastroenterology about age-related gastric changes. Inevitably, an unqualified man formed from the discarded skin cells of Jordan Peterson reared his opinionated head. “No effects”, he stated.

Of course, there’s an effect. Basal salivary gland secretion and sense of taste and smell decrease with age. Dental problems increase, causing problems with chewing and swallowing alongside decreased force in the jaw muscles. The coordination of cricoid cartilage and pharyngeal muscles deteriorate, and there’s a decrease in the efficacy of gastric muscle motility and strength. The lining of our stomach loses elasticity just as our skin does. There’s a rise in the incidence of gastro‐oesophageal reflux disease (GORD) and an increased risk of hiatus hernia as our sphincters relax into older age. The stomach itself undergoes degenerative changes affecting mucous production and secretion of gastric acids: it becomes prone to delayed emptying. Blood flow is reduced. Intestinally, there may be age-related changes in transit time and an increased risk of diverticular and similar diseases. A decrease in lactase levels in the small intestine can make us less able to tolerate dairy foods. Most of this is not pathological in itself. It’s the effects of time, some of which we can influence and some we cannot. In reality, my Bendicks-related crise du foie had nothing to do with my bile duct and everything to do with indigestion. I keep forgetting that I am no longer thirty.

I’ve been thinking about all of this as it relates to the autobiography of my appetite and eating habits. The phrases I use most to capture my story have not changed since I was young, but I have- or at least my appetite has. Ask my grandparents and older family members; they’d have told you that “Nic has the stomach of a goat.” Until my fifties, I did, and although this phrase no longer applies, I have used it on social media to describe my eating within the last year. Food in any combination would happily transit my alimentary tract in the most unproblematic and inconspicuous ways. Unlike My Naughty Little Sister, I could eat an entire trifle and suffer no digestive consequences. I felt no shame in a plate piled high, no self-consciousness about cutting myself an enormous slice of cake, repeat visits to the buffet, salad bar or carvery, and scrapping over a plate of scraps. There was nothing particularly ‘feminine’ about my eating patterns. I was born close enough to the end of the Second World War when cleaning one’s plate and cheerfully eating whatever you were given with no complaint or hesitation were signs of virtue that transcended gender norms to a certain degree. When you don’t have a lot (and the grandparents who brought me up came from humble stock), the affectation by the elite of a fashionably small appetite and fragility of digestion was unthinkable.

Enid Blyton’s stories of boarding school midnight feasts and the resulting crise du foie of the participants were a puzzle to someone who was not afflicted with a ‘delicate stomach’, which I know now to be intensely class and gender-bound. The message is toxic: if you abandon inhibitions and social conventions when you eat, you will pay for it. “You are suffering from Midnight Feast Illness! Aha!” says Matron after wan-faced dyspeptic schoolgirls present themselves to her the morning after. “You needn’t pretend to me! If you will feast on pork pies and sardines, chocolate and ginger beer in the middle of the night, you can expect a dose of medicine from me the next day.” Why on earth were these girls so weak? This is amateur-level feasting, I smugly told myself. Last month I reread some of the books in the series. Midnight feasts, sticky cream buns after a lacrosse match, and half-term picnics spread themselves across the pages. They sound like the fever dream of an author who lived through rationing. And at fifty-six, these scenes made me feel nauseous. Why I was surprised, I don’t know because now I only have to look at footage of fingers being poked into focaccia dough to feel ill, and my gallbladder becomes quite hysterical at the thought of eating sausages cooked over a gas stove in a school music room at midnight.

I’m finding it hard to negotiate all this as a food writer and recipe developer. I do not want my dietary needs to impact my recipe development or constrain what I write about, but the food I love best is the food I can no longer eat without careful planning, which makes recipe testing quite tricky. The need to eat slowly, drink lots of water, exercise after, and avoid certain combinations of ingredients entirely means a longed-for visit to Racine to eat fat-heavy French food probably isn’t happening. I have to turn down a lot of invites because I can no longer feast at night. I worry about what I might be served when I am invited to eat at someone’s home. Of course, I ignore a lot of this and pay the consequences because the heart wants what it wants when it wants it- and my heart is also too embarrassed to make a fuss. But the consequences of ignoring these new dietary rules can be even more embarrassing. I miss being a goat, and I have yet to weave a new and palatable story about my appetite- one that doesn’t make me come across like a vaporous heroine in a bodice-ripper. And, in the meantime, I am reclaiming La Crise Du Foie in all its elegant loucheness. It will do for now.

Please note: whilst surgery to remove a gallstone is recommended in many cases, it is not always a straightforward decision. Other factors can come into play. If you have concerns about your health, please consult a health professional.

Further reading:

‘Gulp’ by Mary Roache is a quirky and well-researched journey around the human digestive system.

The Second Brain: A Groundbreaking New Understanding of Nervous Disorders of the Stomach and Intestine by Michael Gershon does use technical language but is worth reading. “The ugly gut is more intellectual than the heart and may have a greater capacity for feeling,” he writes.

The Diet Myth by Dr Tim Spector is great on fad diets and their effects on the body over a longer period.

Gut Garden: A Journey into the Wonderful World of Your Microbiome by Katie Brosnan is an amusing way to introduce this subject to children.