Metropolitan Australia is suffering from a serious shortage of acute hospital beds. Simplistic comparisons with the Organisation for Economic Co-operation and Development bed numbers are misleading because of the hybrid Australian public/private hospital system. The unavailability of most private beds for acute emergency cases and urban/rural bed imbalances have not been adequately considered. There is a lack of advocacy for acute bed availability. This attitude permeates government, health professions and the health bureaucracy. Planners, politicians, analysts and the media have adopted false hopes of reducing acute demand by prevention and primary care strategies, vital as these services are to a balanced healthcare system. This paper directly challenges the ideology that says Australia depends too heavily on hospital-based healthcare. Rebuilding the bed base requires recognition of the need for an adequate acute hospital service and strong advocacy for bed-based care in the medical and nursing professionals who should be driving policy. The forces opposing bed-based care are strong and solutions might include legislative definition of bed numbers and availability.

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physiological principles of Tympanoplasty (Wullstein, 1953) are adapted. Temporalis muscle fascia is used as scaffolding for the new tympanic membrane. The cases presented are few in number (thirty-four), but consecutive and well documented. The classification corresponds broadly to that of Wullstein: (Type I, for simple Myringoplasty is not considered in this series), Type II for graft on incus, Type III for graft on head of stapes, Type IV for graft on stapes remnants, and Type V for fenestration of the lateral semicircular canal. Ten cases of extended Type I are presented, five of Type II, seventeen of Type III, and two of Type IV-each being an individual adaptation of a general procedure here described as Endaural Tympanoplasty Without Flap. Twenty-nine cases, where all steps of the procedure were strictly adhered to, were successful in every way, and five, where one or other detail was not observed, are considered technical failures. The reasons for failure will be shown. The illustrations are biro-sketches by the author, drawn from memory of actual operations. Indications for ETWOF These are the usual ones for classical tympanoplasties with flap. (1) Six months' dry central perforation causing deafness, when the state of health of the middle ear is still in doubt (Extended Type I). (2) Central perforation persistently moist in spite of healthy upper respiratory tract (Type II, III or IV or Extended Type I). The patient usually wants the operation even if for aesthetic reasons alone, independently of hearing. (3) Middle-ear discharge of doubtful duration-where a simple Schwartze is likely to fail and lead to a second operation (Types II-IV or Extended Type I). (4) Chronic middle-ear suppuration with or without cholesteatoma (Types II-IV or even an Extended Type I). Non-indication Dry central perforation not causing deafness, where the patient does not especially request the operation. Contraindications This must be looked upon as a closed-cavity operation, which is unsafe, in the presence of: ' (i) Labyrinthine fistula. ; (ii) Meningeal involvement, and (iii) Malignancy. Note: Cholesteatoma was encountered in only one of these cases.

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