From the late 1930s onwards Edward Tolstoi (1897-1983) was the major proponent of the “free diet” treatment of diabetes, a stance which brought him into frequent conflict with Joslin and his associates in Boston, a contest he is said to have enjoyed greatly. Among his comments about his regimen were, “I avoid terrorizing the patient and I also do not promise him perfect health if his deportment is faultless” and “[My] patients enjoy their freedom … and it is not necessary for them to carry their insulin and syringe with them. They administer the insulin to themselves in the morning and then put the equipment away until the following morning. These patients are not singled out as a group, apart from their fellow men, and their habits of living approximate the normal.”
Tolstoi was born in Elizabethgrad, in present day Ukraine, and brought to America at the age of 2. He graduated from Yale University in 1919 and Cornell Medical College in 1923. In the late 1920s he worked as a chemist with Frederick Allen at his Physiatric Institute when,
I was indoctrinated with the method in vogue at that time for the treatment of diabetes – a method that starved the patient. The objective was to reduce the blood sugar to perfectly normal levels and to keep the urine sugar free…[after the discovery of insulin] this idea was carried over but it was found rather difficult to keep the patient sugar free for 24 hours so a system of deception developed with the patient and doctor, but as long as the patient got along everybody was happy. 
Tolstoi had a personality clash with the dour Allen, but was encouraged by Eugene du Bois (1882-1959), a pioneer in metabolic medicine, to pursue his research interests at the New York Hospital. He also had a large private practice including several champion tennis players who he helped avoid insulin reactions.
Tolstoi’s ‘conversion’ came in 1936 when he started using protamine insulin as a once daily injection and found that trying to keep the urine sugar free led to alarming reactions which were ‘frightfully sudden in onset, often without warning’. Two patients stayed away from the clinic to avoid the displeasure of their doctors, but eventually came back saying that, in spite of having had continuous glycosuria, they felt well. Both were admitted to the metabolic ward for 50 days where, on one dose of protamine and calculated diet, they could excrete up to 100 grams of sugar in 24 hours yet have a normal urinary volume, have no symptoms of diabetes, be free from ketosis and maintain their weight. For Tolstoi, ‘this was a startling finding indeed. We did not believe it ourselves and nobody else believed us’. He repeated the experiments with identical results and then reasoned that, ‘Since excreting large quantities of sugar exerted no deleterious effects on the patient, why calculate diets? The next step was to let the patients eat what they liked and see what would happen’. That they did not have more infections was, Tolstoi believed, because compared to the pre-insulin era, all were well nourished.
The English physician Joan Walker remembered visiting Tolstoi in 1950 when she found him ‘a most engaging person with bright red hair’. However, she also noted that, ‘all his patients came passing large amounts of sugar and he treated the consequent pruritus vulvae with gentian violet applications.’  To the criticism that his patients would develop complications, he retorted as late as 1952 that ‘the view that retinal changes were due to the hyperglycemia is not too strongly championed today. Most ophthalmologists are of the opinion that the retinitis found in diabetes is the retinitis of arterio-sclerosis’. Also, said Tolstoi, at the Joslin Clinic, where ‘adherence to chemical control is achieved more completely than anywhere else’, only 8% of juvenile diabetics surviving 20 years escaped vascular disease. Another important issue was that of quality of life. Tolstoi claimed that a life saved by insulin must be a life worth living and that treatment must be effective, simple and in no way burdensome. By contrast, advocates of what Tolstoi called ‘the chemical school’, produced patients who, in his words, ‘certainly do not enjoy life nor have the freedom of people who live like normal human beings’.
^ Diabetes Mellitus: Practitioner’s Conference. New York Med 1952;8:16-33.
^ Tolstoi E, Almy TP, Toscani V. Treatment of diabetes mellitus with protamine zinc insulin.Is persistent glycosuria harmful? A metabolic study of a severe case. Ann Int Med 1942;16:893-903.
^ Walker J. Chronicle of a Diabetes Service. London, British Diabetic Association, 1990, p.27.