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Clinical Engineering Handbook

Second Edition
Clinical Engineering
Handbook
Second Edition

Editor-in-Chief

Ernesto Iadanza
IFMBE HTA Division Chair, Adjunct Professor in Clinical Engineering
at the School of Engineering
Università degli Studi di Firenze
Florence, Italy
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 Dedication

This Handbook is dedicated to the memory of my first mentor,

Professor ­Silvano Dubini.
 Section Editors

Saide Jorge Calil Almir Badnjević

Department of Biomedical Engineering, Faculty of Department of Genetics and Bioengineering, Faculty of
Electrical Engineering and Computing, University of Engineering and Natural Sciences, International Burch
Campinas, Campinas, Brazil University; Medical Device Inspection Laboratory Verlab
Ltd.; Medical Devices Verification Laboratory Verlab Ltd.,
Thomas M. Judd Sarajevo, Bosnia and Herzegovina
Clinical Engineering Division, IFMBE, Marietta, GA;
Health & Information Technology & Quality, The Elliot B. Sloane
Permanente Journal, Portland, OR; Foundation for Living, Foundation for Living, Wellness, and Health, Osprey, FL;
Wellness, and Health, Osprey, FL; Computing Sciences, Computing Sciences, Villanova University, Villanova, PA,
Villanova University, Villanova, PA; Quality Assessment, United States
Improvement and Reporting, Kaiser Permanente Georgia
Region, Atlanta, GA, United States Ricardo J. Silva
Computing Sciences, Villanova University, Villanova, PA;
James O. Wear Foundation for Living, Wellness, and Health, Orlando,
Scientific Enterprises, North Little Rock, AR, FL, United States; Montenegro Institute for Cognitive
United States Disabilities, Guayaquil, Ecuador

Mladen Poluta
Monique Frize
Western Cape Government: Health, Cape Town, South Africa
Systems and Computer Engineering, Carleton University,
Ottawa, ON, Canada
Leandro Pecchia
School of Engineering, University of Warwick, Coventry,
Gerald R. Goodman United Kingdom
Health Care Administration, Texas Woman’s University,
Houston, TX, United States Raj M. Ratwani
National Center for Human Factors in Healthcare, MedStar
Luca Radice Health; Georgetown University School of Medicine,
Medical Device Industries Consulting, Seveso, Italy Washington, DC, United States

xxxiii
Contributors

Numbers in paraentheses indicate the pages on which the authors’ Simone Borsci (807,829) Department of Cognitive
contrbutions begin. Psychology and Ergonomics, Faculty of Behavioural
Natalie Abts (871) National Center for Human Factors Management and Social Sciences, University of Twente,
in Healthcare, MedStar Institute for Innovation, Enschede, The Netherlands; National Institute for
Washington, DC, United States Health Research, London IVD Co-operative, Faculty of
Medicine, Department of Surgery & Cancer, Imperial
Arti Devi Ahluwalia (7) Research Center E. Piaggio and
College, London; School of Creative Arts, University of
Department of Information Engineering, University of
Hertfordshire, Hertfordshire, United Kingdom
Pisa, Pisa, Italy
Alen Bošnjaković (731,753) Institute of Metrology
Hashem O. Al-Fadel (111) Temos Assessors Advisory
of Bosnia and Herzegovina, Sarajevo, Bosnia and
Board, Temos International Healthcare Accreditation,
Herzegovina
Germany
Russell J. Branaghan (847) Human Systems Engineering
Martina Andellini (812) HTA Unit, Bambino Gesù
Program, Ira A. Fulton Schools of Engineering, Arizona
Children’s Hospital, IRCCS, Rome, Italy
State University, Mesa, AZ, United States
Ryan Arnold (858) Drexel University College of Medicine, Marta Bravi (52) Health Technologies Procurement—
Philadelphia, PA, United States ESTAR, Florence, Italy
Roberto Ayala (82) Health Technology Excellence Rebecca L. Butler (865) National Center for Human
National Center, Mexico City, Mexico Factors in Healthcare; Quality and Safety, MedStar
Almir Badnjević (477,478,484,491,498,503,509,514,520, Health; Georgetown University School of Medicine,
713,715,722,731,774,780) Department of Genetics and Washington, DC, United States
Bioengineering, Faculty of Engineering and Natural Sam S. Byamukama (161) Mark Biomedical Limited,
Sciences, International Burch University; Medical Kampala, Uganda
Device Inspection Laboratory Verlab Ltd.; Devices
Verification Laboratory Verlab Ltd., Sarajevo, Bosnia Saide Jorge Calil (61) Department of Biomedical
and Herzegovina Engineering, Faculty of Electrical Engineering and
Computing, University of Campinas, Campinas – SP,
Matthew F. Baretich (208,349,384,667,674) Baretich Brazil
Engineering, Inc., Fort Collins, CO, United States
Javier Enrique Camacho-Cogollo (33) Biomedical
Paula Berrio (181,186) Clinical Engineering Department, Engineering, EIA University, Envigado, Colombia
Hospital Pablo Tobón Uribe, Medellin, Colombia;
Joel R. Canlas (436) Clinical Engineering and Technology
COLCINC, Bogota, CO, United States
Management Department, Beaumont Services
Li Bin (114) Shanghai Medical Equipment Quality Control Company, LLC, Royal Oak, MI, United States
Center, Shanghai, China
Carole C. Carey (764) C3-Carey Consultants, LLC, Fulton,
J.J.B. Pierre Blais (357) INNOVAL Failure Analysis, MD, United States
Ottawa, ON, Canada
Rossana Castaldo (799) School of Engineering, University
H. Joseph Blumenthal (887) National Center for Human of Warwick, Coventry, United Kingdom
Factors in Healthcare, MedStar Health, Washington, Mario Castañeda (178,281) President, HealthiTek, Inc., San
DC, United States Rafael, CA; Clinical Engineering Division, IFMBE,
Isis Bonet (33) Computer and Systems Engineering, EIA Marietta, GA; Health & Information Technology & Quality,
University, Envigado, Colombia The Permanente Journal, Portland, OR, United States

xxxv
xxxvi  Contributors

Noel C. Castro (101) Montenegro Institute for Cognitive School of Public Health; Center for TeleHealth and
Disabilities, Guayaquil, Ecuador; Department of Biomedical Engineering Department, Texas Children’s
Electronics and Circuits, Simon Bolivar University, Hospital; Global Clinical Engineering Journal, Houston,
Caracas, Venezuela TX, United States
Claudio Cecchini (128) Department of Clinical Engineering, Carol Davis-Smith (393) Carol Davis-Smith & Associates,
ASST Valtellina e Alto Lario, Sondrio, Italy LLC, Phoenix, AZ, United States
Emel Çetin (742) Medical Metrology Laboratory, TÜBİTAK Roxana di Mauro (812) HTA Unit, Bambino Gesù
National Metrology Institute, Kocaeli, Turkey Children’s Hospital, IRCCS, Rome, Italy
Anthony Chan (321) Biomedical Engineering Technology, Licia Di Pietro (7) Research Center E. Piaggio and
School of Health Sciences, British Columbia Institute Department of Information Engineering, University of
of Technology; School of Biomedical Engineering, Pisa, Pisa, Italy
University of British Columbia, Vancouver, BC,
Canada David Dickey (222) Medical Equipment Organization,
Bristol, United Kingdom; Medical Technology
Guo Chenchen (114) Clinical Engineering, Children’s Management, Inc., Clarkston, MI, United States
Hospital of Zhejiang University School of Medicine,
Hangzhou, China Hüseyin Okan Durmuş (742) Medical Metrology
Laboratory, TÜBİTAK National Metrology Institute,
Michael Cheng (321,353,357) Biomedical Engineer, Kocaeli, Turkey
Patient Safety/Education Advocate, Ottawa, ON, Canada
Hala Durrah (881) MedStar Health Research Institute and
Oriana Ciani (789,795) Center for Research on Health MedStar National Center for Human Factors in Healthcare,
and Social Care Management, SDA Bocconi, Milan, MedStar Health, Washington, DC, United States
Italy; Evidence Synthesis & Modelling for Health
Improvement, University of Exeter Medical School, Zijad Džemić (715,722,731) Institute of Metrology
Exeter, United Kingdom of Bosnia and Herzegovina, Sarajevo, Bosnia and
Herzegovina
Daniel Clark (63) Clinical Engineering, Nottingham
University Hospitals NHS Trust; Faculty of Engineering, Antony Easty (330) Institute of Biomaterials & Biomedical
University of Nottingham, Nottingham, United Kingdom Engineering (IBBME), University of Toronto, ON,
Canada
J. Tobey Clark (227,281,410) WHO Collaborating Center
for Health Technology Management, Technical Services Alice L. Epstein (186,196,308,335,699) Allied Health Risk
Partnership, University of Vermont, Burlington, VT; Control, CNA; CNA Insurance, Durango, CO, United
Clinical Engineering Division, IFMBE, Marietta, GA; States
Health & Information Technology & Quality, The Jonathan Erskine (321,353) European Health Property
Permanente Journal, Portland, OR, United States Network, Durham University, Durham, United Kingdom
Theodore Cohen (208,384,543) Clinical Engineering, UC Lourdes Escobar (871) Hospital Universitario Marqués de
Davis Health, Fair Oaks, CA, United States Valdecilla, Santander, Spain
Giovanni Conte (52) Health Technologies Procurement—
Carlo Federici (789,799) Center for Research on Health
ESTAR, Florence, Italy
and Social Care Management, SDA Bocconi, Milan,
Todd Cooper (611) True Health Trust, San Diego, CA, Italy; School of Engineering, University of Warwick,
United States Coventry, United Kingdom
Bonacini Daniele, CEO (458) Roadrunnerfoot Engineering Jose Alberto Ferreira Filho (108) Instituto de Engenharia
srl, Pregnana Milanese; Politecnico of Milan, Milan, de Sistemas e Tecnologia da Informação, Universidade
Italy Federal de Itajubá, Itajubá, Minas Gerais, Brazil
Luis Danyau (143) School of Biomedical Engineering, G. Fico (807) IFMBE, HTA Division, Eindhoven, The
University of Valparaiso, Valparaiso, Chile Netherlands; Department of Photonics and Biomedical
Lida Z. David (829) Department of Cognitive Psychology Engineering, Life Supporting Technologies Research
and Ergonomics, Faculty of Behavioural Management Group, Universidad Politécnica de Madrid, Madrid,
and Social Sciences, University of Twente, Enschede, Spain
The Netherlands Allan Fong (876) National Center for Human Factors in
Yadin David (15,148,166,243,362,550) Biomedical Healthcare, MedStar Health, Washington, DC, United
Engineering Consultants, LLC; University of Texas States
 Contributors  xxxvii

William Frank (670) Medical Gas Services, Inc., Webster, Peter Heimann (236) Healthcare, Luxembourg
NH, United States Development, Vientiane, Laos
Ella S. Franklin (852) National Center for Human Antonio Hernandez (178,243,259,276,281) Consultant on
Factors in Healthcare, MedStar Institute for Innovation, Healthcare Technology, Washington, DC; University
Washington, DC, United States of Texas School of Public Health, Houston, TX;
Monique Frize (329,330) Systems and Computer PAHO Health Technology Regional Adviser; Health
Engineering, Carleton University, Ottawa, ON, Canada Technology Consultant, Washington, DC; Clinical
Engineering Division, IFMBE, Marietta, GA; Health
Tidimogo Gaamangwe (321,353) Clinical Engineering & Information Technology & Quality, The Permanente
Program, Winnipeg Regional Health Authority, Journal, Portland, OR, United States
Winnipeg, MB, Canada
Diógenes Hernández (694) PAHO/WHO, Panama City,
Jonathan A. Gaev (428) International Programs, ECRI, Panama
Plymouth Meeting, PA, United States
Laura Herrero-Urigüen (871) Valdecilla Biomedical
Beatriz Galeano (181,186) Universidad Pontificia Research Institute (IDIVAL), Santander, Spain
Bolivariana, Medellín, Colombia; COLCINC, Bogota,
CO, United States Ethan Hertz (736) Clinical Engineering Department, Duke
Health Technology Solutions, Duke University Health
Pedro Galvan (87) Biomedical Engineering Department, System, Durham, NC, United States
Health Sciences Research Institute, San Lorenzo,
Paraguay Aaron Zachary Hettinger (876,887) National Center
for Human Factors in Healthcare, MedStar Health;
William M. Gentles (72,205,208,268) BT Medical
Georgetown University School of Medicine,
Technology Consulting; University of Toronto;
Washington, DC, United States
Canadian Medical & Biological Engineering Society,
Toronto, ON, Canada Rabeh Robert Hijazi (219) Healthcare Technology
Professional, Detroit, MI, United States
Germán Giles (125) Engineering Department, Medical
Foundation of Mar del Plata, Mar del Plata; National Daniel J. Hoffman (887) National Center for Human
Technological University - San Nicolas Regional Factors in Healthcare, MedStar Health, Washington,
College, San Nicolás, Buenos Aires, Argentina DC, United States
Gerald R. Goodman (377,378,728) Health Care Jessica L. Howe (865) National Center for Human
Administration, Texas Woman’s University, Houston; Factors in Healthcare; Quality and Safety, MedStar
Houston Institute of Health Sciences, Texas Women’s Health; Georgetown University School of Medicine,
University, TX, United States Washington, DC, United States
Stephen L. Grimes (253,290) Strategic Healthcare Xia Huiling (114) Clinical Engineering, Inner Mongolia
Technology Associates, LLC, Swampscott, MA, United Autonomous Region People’s Hospital, Hohhot, China
States J.M. Hummel (807) IFMBE, HTA Division; Philips
C. Guillermo Avendaño† (143) School of Biomedical Research, Royal Philips, Eindhoven, The Netherlands
Engineering, University of Valparaiso, Valparaiso, Chile Bruce Hyndman (657,662) Community Hospital of the
Lejla Gurbeta Pokvić (478,484,491,498,503,509,514,520, Monterey Peninsula, Monterey, CA, United States
753,774) Department of Genetics and Bioengineering, Ernesto Iadanza (1,3,33,42,128,330,832) IFMBE HTA
Faculty of Engineering and Natural Sciences, International Division, School of Engineering, University of Florence,
Burch University; Medical Device Inspection Laboratory Florence, Italy
Verlab Ltd., Sarajevo; Technical Faculty University of
Bihać, Bihać, Bosnia and Herzegovina Andrea Garcia Ibarra (181,186) Drugs and Health
Technology Department, MoH Colombia, Bogotá,
Jay W. Hall (436) John D. Dingell VA Hospital-Detroit, Colombia
Detroit, MI, United States
Hiroki Igeta (105) Dept. of Clinical Engineering, Aso
Gary H. Harding (186,196,308,335,699) Health Care, Iizuka Hospital, Iizuka, Japan
Greener Pastures, Durango, CO, United States
Rohit Inamdar (616) Applied Solutions, ECRI Institute,
Plymouth, PA, United States
Andrei Issakov (236) Process Management System, Sarl,
†
Deceased Geneva, Switzerland
xxxviii  Contributors

Akhila Iyer (852) National Center for Human Factors Marcelo Lencina (125) Engineering Department, Medical
in Healthcare, MedStar Institute for Innovation, Foundation of Mar del Plata, Mar del Plata; National
Washington, DC, United States Technological University - San Nicolas Regional
Jadwiga Jodi Strzelczyk (677) Radiological Sciences College, San Nicolás, Buenos Aires, Argentina
Division, University of Colorado, Health Sciences Alessio Luschi (42) Department of Information
Center, Denver, CO, United States Engineering, University of Florence, Florence, Italy
Thomas M. Judd (15,165,166,178,236,243,259,280, Douglas Magagna (682) Engenhária Clínica Ltda., São
281,290,530,648) Clinical Engineering Division, Paulo, Brazil
IFMBE, Marietta, GA; Health & Information Technology
Lúcio Flávio de Magalhães Brito (682) Engenhária
& Quality, The Permanente Journal, Portland, OR;
Clínica Ltda., São Paulo, Brazil
Foundation for Living, Wellness, and Health, Osprey,
FL; Computing Sciences, Villanova University, Carmelo De Maria (7) Research Center E. Piaggio and
Villanova, PA; Quality Assessment, Improvement and Department of Information Engineering, University of
Reporting, Kaiser Permanente Georgia Region, Atlanta, Pisa, Pisa, Italy
GA, United States Ranjana K. Mehta (839) Industrial and Systems
Baki Karaböce (742) Medical Metrology Laboratory, Engineering, Texas A&M University, College Station,
TÜBİTAK National Metrology Institute, Kocaeli, TX, United States
Turkey Haris Memić (715,722) Department for Legal Metrology,
James P. Keller (451) Business Development Director, Institute of Metrology of Bosnia and Herzegovina,
Emergo by UL, Austin, TX, United States Sarajevo, Bosnia and Herzegovina
Kathryn M. Kellogg (865) National Center for Human Kristen E. Miller (858,876) National Center for Human
Factors in Healthcare, MedStar Health; Quality and Factors in Healthcare, MedStar Health; Georgetown
Safety, MedStar Health; Georgetown University School University School of Medicine, Washington, DC,
of Medicine, Washington, DC, United States United States
Eben Kermit (390) Biomedical Engineering, Stanford Michael B. Mirsky (421) Clinical Engineering Solutions
Health Care, Stanford, CA, United States Yorktown Heights, Yorktown Heights, NY, United States
Baset Khalaf (321) Clinical Engineering, Tshwane Brian Moher (321,353) Health Law & Medical Devices;
University of Technology, Pretoria, South Africa Patient Safety, Toronto, ON, Canada
Niranjan D. Khambete (132) Department of Clinical Luis Montesinos (821) School of Engineering and Sciences,
Engineering, Deenanath Mangeshkar Hospital and Tecnologico de Monterrey, Mexico City, Mexico
Research Centre, Pune, India
Massimiliano Monti (52) Health Technologies - AOU
Tracy C. Kim (865) National Center for Human Factors Careggi/Meyer—ESTAR, Florence, Italy
in Healthcare, MedStar Health; Quality and Safety,
Yoon Moonsoo (321) Global Health Department, Public
MedStar Health; Georgetown University School of
Health Graduate School, Yonsei University, Seoul,
Medicine, Washington, DC, United States
South Korea
Gary Klein (858) Shadowbox, LLC, Dayton, OH, United
Ed Napke (321,353) Health Canada; World Health
States
Organization Drug Adverse Event Expert, Queen
Zheng Kun (114) Clinical Engineering, Children’s Hospital Elizaberth Jubilee Medal, Ottawa, ON, Canada
of Zhejiang University School of Medicine, Hangzhou,
Åke Öberg (446) Linköping University, Linköping, Sweden
China
Stacie Lafko (847) Human Systems Engineering Program, Frank R. Painter (393) University of Connecticut, Storrs,
Ira A. Fulton Schools of Engineering, Arizona State CT, United States
University, Mesa, AZ, United States Tadeusz Pałko (137) Institute of Metrology and Biomedical
Andres Diaz Lantada (7) Department of Mechanical Engineering, Warsaw Technical University, Warsaw,
Engineering, Universidad Politécnica de Madrid, Poland
Madrid, Spain Nicolas Pallikarakis (832) University of Patras, Patras, Greece
Leo Lehtiniemi (321,353) Health Canada; Methodology W. David Paperman (362) Clinical Engineering
Consultant, Ottawa, ON, Canada Consultant, Cut and Shoot, TX, United States
 Contributors  xxxix

Leandro Pecchia (330,787,799,818,821,832) School of Pamela Y. Shuck (436) McLaren Health Care, Flint, MI,
Engineering, University of Warwick, Coventry, United United States
Kingdom Ricardo J. Silva (101,527,530,556,611,638,644)
Davide Piaggio (818,832) School of Engineering, Computing Sciences, Villanova University, Villanova,
University of Warwick, Coventry, United Kingdom PA; Foundation for Living, Wellness, and Health,
Ledina Picari (151) Medical Devices and Systems Unit, Orlando, FL, United States; Montenegro Institute for
Ministry of Health of Albania, Tirana, Albania Cognitive Disabilities, Guayaquil, Ecuador
Julie Polisena (330,795) Medical Devices & Clinical Hardeep Singh (858) Michael E. DeBakey Veterans Affairs
Interventions, CADTH; Canadian Agency for Drugs and Medical Center, Baylor College of Medicine, Houston,
Technologies in Health (CADTH), Ottawa, ON, Canada TX, United States
Mladen Poluta (156,655) Western Cape Government: Elliot B. Sloane (527,530,556,569,611,638,644,648)
Health, Cape Town, South Africa Foundation for Living, Wellness, and Health, Osprey,
Luca Radice (427,469) Medical Device Industries FL; Computing Sciences, Villanova University,
Consulting, Seveso, Italy Villanova, PA, United States

Arjun H. Rao (839) Industrial and Systems Engineering, Peter Smithson (222) Medical Equipment Organization,
Texas A&M University, College Station, TX, United States Bristol, United Kingdom; Medical Technology
Management, Inc., Clarkston, MI, United States
Raj M. Ratwani (837,876) National Center for Human Factors
in Healthcare, MedStar Health; Georgetown University Ira Soller (421) Scientific and Medical Instrumentation,
School of Medicine, Washington, DC, United States SUNY Health Science Center at Brooklyn, Brooklyn,
NY, United States
Alice Ravizza (7) Department of Mechanical and Aerospace
Engineering, Politecnico di Torino, Torino, Italy Lemana Spahić (478,484,491,514) Department of Genetics
and Bioengineering, Faculty of Engineering and Natural
Adrian Richards (140) Biomedical Engineering, The
Sciences, International Burch University, Sarajevo,
Women’s and Children’s Health Network, Adelaide,
Bosnia and Herzegovina
SA, Australia
Robert T. Ssekitoleko (161) College of Health Sciences,
Malcolm G. Ridgway (373) Retired Clinical Engineer,
Makerere University, Kampala; Knowledge for Change
Woodland Hills, CA, United States
(K4C), Fort Portal, Uganda
Matteo Ritrovato (812) HTA Unit, Bambino Gesù
Lucy Stein (852) National Center for Human Factors
Children’s Hospital, IRCCS, Rome, Italy
in Healthcare, MedStar Institute for Innovation,
Rossana Rivas (94) Eng. Dep. & Health Technopole Washington, DC, United States
CENGETS, Pontifical Catholic University of Peru
PUCP, Lima, Peru Arif Subhan (219) Department of Veterans Affairs, Los
Angeles, CA, United States
Stanislao Rizzo (52) Department of Ophthalmology,
University of Florence, Florence, Italy David Tacconi (473) CoRehab, Trento, Italy
Elena Rojo (871) Hospital Virtual Valdecilla, Santander, Nilgün Tokman (742) Medical Metrology Laboratory,
Spain TÜBİTAK National Metrology Institute, Kocaeli, Turkey
Jiang Ruiyao (114) Clinical Engineering, Shanghai 6th Eduardo Toledo (94) Eng. Dep. & Health Technopole
People’s Hospital, Shanghai, China CENGETS, Pontifical Catholic University of Peru
PUCP, Lima, Peru
Farzan Sasangohar (839) Industrial and Systems
Engineering, Texas A&M University, College Station; P. Trbovich (330) Institute of Health Policy, Management
Center for Outcomes Research, Houston Methodist and Evaluation, University of Toronto, ON, Canada
Hospital, Houston, TX, United States Priyanka Upendra (390) Technology Management,
Francesca Satta (52) Health Technologies - AOU Careggi/ Banner Health, Phoenix, AZ, United States
Meyer—ESTAR, Florence, Italy Luis Vilcahuaman (94) Eng. Dep. & Health Technopole
Peter A. Schilder (707) Saftek Consulting (Pty) Ltd., Cape CENGETS, Pontifical Catholic University of Peru
Town, South Africa PUCP, Lima, Peru
Garrett Seeley (402) Biomedical Equipment Technology, Jorge Enrique Villamil Gutiérrez (75) Manuela Beltrán
Texas State Technical College, Waco, TX, United States University, Bogotá D.C., Colombia
xl  Contributors

Maja Peklić Vitt (715,753) Regulatory and Clinical Affairs Deliya B. Wesley (881) MedStar Health Research Institute and
Expert, Freiburg im Breisgau, Germany MedStar National Center for Human Factors in Healthcare,
Dijana Vuković (780) Faculty of Economics, University of MedStar Health, Washington, DC, United States
Bihac, Bihac, Bosnia and Herzegovina Dinsie Williams (795) Canadian Agency for Drugs and
Sam S.B. Wanda (161) Uganda National Association for Technologies in Health (CADTH), Ottawa, ON, Canada
Medical and Hospital Engineers, Kampala, Uganda Axel Wirth (253) US Healthcare Industry, Symantec
James O. Wear (289,297,377,416) Scientific Enterprises, Corporation
North Little Rock, AR, United States Rachel Wynn (881) MedStar Health Research Institute and
Danielle L.M. Weldon (887) National Center for Human MedStar National Center for Human Factors in Healthcare,
Factors in Healthcare, MedStar Health, Washington, MedStar Health, Washington, DC, United States
DC, United States Ewa Zalewska (137) Nalecz Institute of Biocybernetics
Joseph P. Welsh (648) Foundation for Living, Wellness, and Biomedical Engineering PAS, Warsaw, Poland
and Health, Osprey, FL; Computing Sciences, Villanova Raymond Peter Zambuto (166,384) Ashland; CEO
University, Villanova, PA, United States Technology in Medicine, Inc., Holliston, MA, United States
Foreword

The Sustainable Development Goals were launched in in science, technology, and clinical research. Revolutions of
2015 as 17 goals to transform the world. The health-related such scale and complexity are unprecedented in human his-
one, number 3, on good health and well-being, requires tory, and they require professionals to be aware and open
availability and appropriate use of medical technologies, to take coherent advantage of the burgeoning discoveries to
which is precisely the scope of this Clinical Engineering impact people’s health.
Handbook. While the modern world has many forms of “vertical”
Therefore, it is imperative to be ethical and professional, intelligence sectors—organized in academia, government,
and constantly attempt to improve the way all medical tech- industry, patients, and general population—a new challenge
nology is managed, to ensure universal health coverage, is to provide “horizontal” intelligence that enables the verti-
support health emergencies and outbreaks, and improve cal expertise to interact and evolve coherently in a respon-
population well-being. These goals are our professional re- sible, ethical, and conscious way to aim for a better world.
sponsibility and together we can accomplish it. As clinical The disjointed results in medical technology are often
engineers, let us continue to strive for it, wherever we live, costly, wasteful, stressful, inefficient, and sometimes even
wherever we are, for patients all around the world. Fifteen cause adverse events in health care. Clinical engineering at-
years ago, the first edition of this outstanding Handbook tempts to reduce these dysfunctions through a comprehen-
was published by Joe Dyro, and exponential developments sive program of professional education and specializations
in science and technology have impacted the health sector that fill critical gaps in institutional plans and processes.
since then. This second edition, led by Ernesto Iadanza and At the same time that new technologies are extending
multiple global authors, who have much advanced the clini- diagnostic and therapeutic capabilities from the macro level
cal engineering profession in their own settings, from hospi- down to the molecular and nanoscales of granularity, health-
tals and governments, to regional and global organizations, care services in many countries are expanding dramatically
all around the world, and have reinforced the development outward, beyond the traditional hospital-centric model into
and implementation of each of the facets hereby presented. homes, gyms, schools, and wearable sensors, as well as
The World Health Organization (WHO) has a specific via cellphones, tablets, mobile clinics, teleconsultations,
unit dedicated to medical devices that has collected global and portable diagnostic devices to remote, low-resource
information and developed guidance on policies, regulatory regions. This veritable flood of innovations poses signifi-
process, procurement, health technology assessment, com- cant, often destabilizing challenges for healthcare systems
puterized maintenance systems, and even lists of essential and worldwide, because public expectations escalate easily and
priority medical devices for clinical interventions by disease most hospitals and health authorities are not well equipped
areas, searching for an international nomenclature which will to track, evaluate, and incorporate changes of such mag-
support the global management of medical devices across nitude, complexity, cost, and functional interdependency.
healthcare sector stakeholders and produce guidance for all These changes originate across a wide spectrum of “verti-
countries. All of these tools form the standard direction to cal” scientific, technological, and clinical disciplines that
support better healthcare technology management and serve in many cases do not consider the ultimate impacts of such
as a basic framework for the compilation of resources pre- changes on the healthcare systems, and systems of sys-
sented throughout the various sections of this Handbook. tems that ultimately must integrate these innovations suc-
As can be noted in the Handbook, the role of the clini- cessfully and affordably for the benefit of patients and the
cal engineer has increased in scope and has overcome ­general population.
challenges globally. However, many challenges remain, es- The current innovation revolutions range across areas
pecially in low resource settings, and need to be tackled in a as diverse as biomimetic engineering, electronic medical
global and interactive manner. records, telehealth technologies, crowd-sourced pandemic
The world of health care is going through multiple revo- tracking, Big Data, telemedicine, robotics, 3D print-
lutions simultaneously as a result of accelerating innovations ing of prosthetics and organ tissue to nano- and molecular

xli
xlii  Foreword

e­ ngineering, m­ iniaturization of lab ­analytics, disaster man- s­ ectors in a more methodical and proactive manner as indi-
agement, microbiomes, and epigenetics. These innovations cated in the WHO medical devices technical series—from
put considerable change pressure on all healthcare systems, national policy, regulation, technical standards, professional
organizationally and individually—from national to local education, academic and industry R&D, device and service
levels—requiring increased attention to the design and as- design, prototyping, clinical research and trials, technology
sessment of medical devices, and to the multiple interdepen- assessment, contracting, supply chain and service strategy,
dencies that exist between medical devices, clinical and IT deployment, integration with IT and business systems, op-
processes, business systems, accreditation standards, staffing erational monitoring, process reengineering, device main-
models, scopes of professional practice, and expanding ser- tenance and repairs, hazard alerts and recalls, inventory
vice models oriented toward wellness promotion, the “medi- analysis, and replacement planning. This “lifecycle” intel-
cal home,” and “care anywhere.” ligence is an essential professional resource for any 21st-
Clinical engineering is a profession whose purpose is century healthcare innovator, manufacturer, planner, care
to understand, manage, and improve the lifecycle of oper- provider, or relevant government agency.
ational complexities of medical devices, systems, and ser- Clinical engineering is emerging as a mission-critical
vices in a disciplined and skilled manner, building on core profession for 21st-century health care, helping to or-
competencies that are augmented over time with specialized chestrate the diverse technical, clinical, and operational
training and project work with diverse stakeholders spanning concerns within a systems orientation that is dynamic, com-
the healthcare sector. Clinical engineers increasingly work prehensive, and evolutionary, in keeping with the enormous
across the entire spectrum of employment sectors to improve promise of the times. This book is a major contribution to
the design of medical devices and services, to improve stan- the evolution of the profession itself, and serves as a call to
dards and policies, to bring practical clinical experience into institutional leaders to look to clinical engineering to ex-
biomedical engineering projects at academic and R&D (re- pand the professional capabilities that healthcare systems
search and development) settings, and to provide ongoing need worldwide as they grapple with the often overwhelm-
expertise in the integration of healthcare innovations in hos- ing complexities, always keeping the end-user perspective
pitals, clinics, and decentralized services worldwide. of patients, and healthcare workers’ needs globally.
Through evidence-based understanding of the “system
lifecycle” of medical innovations, clinical engineers can Adriana Velazquez
help to integrate the vertical intelligences of the various Senior Advisor on Medical Devices, World Health Organization
Acknowledgments

I thank all the authors for their patience, professionalism, My special thanks goes to my father, to my children, and
and friendship shown throughout the long and demanding to my beloved better half, Gabriella, who has never spared
process of writing this important Handbook. A very heart- her support and her patience throughout these long two
felt thanks to all the section editors, who honor me with years of writing.
their friendship and have masterfully coordinated the work
of many colleagues.

xliii
Introduction

Clinical engineering e­ lectromagnetic interference in hospitals and a retrospec-

tive look at electrical safety round out this section.
The purpose of this second edition of the Clinical Engineering
Handbook is to provide a body of knowledge to all clinical
engineers who intend to practice their profession. The level Professionalism, education, and ethics
of medical equipment complexity and the required skills to
manage it are expanding at a tremendous rate. This is clearly Many aspects of professionalism have been addressed
reflected in the first section of the book, where hot topics over the years by some important associations, including
such as open-source medical devices, RFID, and facilities the International Federation for Medical and Biological
management are described, together with a long list of suc- Engineering (IFMBE) and the American College of Clinical
cess stories about clinical engineers from all over the world. Engineering (ACCE). Programs for certification and intern-
ship, training, distance education, in-service education, and
ethics are discussed in Section 6.
Worldwide clinical engineering practice
The context of clinical engineering can vary tremendously
from country to country. A highly detailed panorama of Medical devices: Design, manufacturing,
the situation in 21 countries, from all the continents of the evaluation, control, utilization, and
world, is provided in Section 2. service
Clinical engineers are very much involved in the whole
Health technology management ­lifecycle of a medical device, including its earliest stages,
One of the core disciplines in clinical engineering is the such as design and manufacturing. Comparative evaluations
management of healthcare technologies, involving assess- influence medical device research and design. Cutting-
ment, evaluation, procurement, control, asset management, edge technologies, such as surgical robots, are the result of
maintenance and repair, replacement planning, and more choral teamwork involving clinical engineers as core pro-
tasks. Sections 3 and 4 provide the reader with 22 chapters, fessional figures. Sections 7 and 8 provide the reader with
which dig into the details of each of these essential processes both a comprehensive picture of the above topics as well
and reflect the profound experience of professional leaders as a detailed description of the utilization and service of
from all over the world. Many tools, techniques, and some anesthesia machines, cardiovascular techniques and tech-
tricks can be found here, ready to be used in daily practice. nology, devices inspections, hospital beds, equipment for
intensive care units, devices for imaging, and incubators.
Safety
Information technology and mobile apps
The safety of patients, users, and healthcare structures is
one of the main reasons why clinical engineering simply ex- Twenty-first-century hospitals are steeped in computer sci-
ists. Preventing and managing the risks related to the use of ence. Designing the information systems and the integration
medical devices, in particular, is a core activity that requires and convergence of medical and information technologies
the perfect mastery of the techniques, programs, and regu- are key roles for clinical engineers today, as opposed to only
lations described in Section 5. Today wireless technologies a few short years ago. Clinical decision support systems,
are pervasive; numerous devices produce and are recep- very often exploiting artificial intelligence techniques, are
tive to electromagnetic fields, requiring attention to the ef- overwhelmingly entering our healthcare structures, some-
fects of interference caused by this energy. Key chapters on times revolutionizing the traditional chain of procurement

xlv
xlvi  Introduction

and management. This new scenario implies new aspects p­ roperties, effects and/or impacts of health technologies
about emerging interoperability standards for apps and the and interventions. It covers both the direct, intended con-
internet of things. Also, management of these complex in- sequences of technologies and interventions and their indi-
teroperable systems poses new challenges for clinical en- rect, unintended consequences.” Mastering these concepts
gineers, often involving forensic engineering. All of these and tools is vital to “inform policy and decision-making in
topics are thoroughly addressed in Section 9. health care, especially on how best to allocate limited funds
to health interventions and technologies.”
In Section 12, readers are exposed to many aspects of
Engineering the clinical environment, HTA that are particularly significant for assessing medical
medical device standards, regulations, devices: health economics, early stage HTA, tools such as
and the law multicriteria decision analysis (MCDA), how to teach HTA
It is critical to ensure a safe and well-run environment in all to biomedical engineers, and many others.
the places where medical care is offered to patients. The en-
gineering of physical plants, heating, ventilation, electrical Introduction to human factors
power, the design and management of medical gas systems,
Section 13 closes this Handbook with an interesting intro-
and disaster planning are just some of the key topics ad-
duction to human factors engineering, a journey through
dressed by Section 10. In Section 11, the reader will find an
the physiological and psychological aspects, cognitive er-
up-to-date overview of the most important regulations and
gonomics, safety science and cognitive informatics, which
laws for both hospital facilities safety and medical device
will enrich the reader’s cultural background with skills and
manufacturing and management, from a global perspective.
tools that are rarely covered in normal training courses for
biomedical and clinical engineering.
Health technology assessment Ernesto Iadanza
The World Health Organization defines health technol- Editor-in-Chief
ogy assessment (HTA) as “the systematic evaluation of Florence, Italy
Section 1

Clinical engineering
Ernesto Iadanza
IFMBE HTA Division, School of Engineering, University of Florence, Florence, Italy

Ask any clinical engineer what other work he would have the hard task of acting as a mediator between such d­ ifferent
done if he had not become an engineer. The answer, with cultures, basing his work on the multidisciplinary nature of
very few exceptions, will always be the same: the doctor! his own skills.
In the word “clinical” itself the closeness of this profes- The dizzying speed at which healthcare technologies are
sional figure to the patient is inherent. A proximity, even progressing complicates things. Today’s hospitals are built
physical, represents an absolute exception in the vast field and managed in an extremely different way from what it has
of engineering. The clinical engineer is immersed in the been just 30 years ago. Telecommunications networks and
healthcare environment, without any doubt the most com- infrastructure in general have changed dramatically over the
plex environment imaginable, both from the point of view last 20 years. Today’s medicine is very different from that
of the quantity of risks present and from the point of view of just 10 years ago.
of the highly advanced technology present. All these require that the clinical engineer constantly
Try to compare a hospital to any other production process renew his skills, his way of working, and even his own lan-
(yes, this is what is done in hospitals: producing health!) and guage, throughout his professional life.
you will immediately realize the very high complexity that In this section of the Clinical Engineering Handbook we
characterizes every healthcare structure. The very presence wanted to give a “bird’s eye” picture of the above.
of the patient inside the structure introduces a high quantity The first chapter illustrates the evolution of the profes-
of risk factors which must be taken into account for safety sion, describing the high level of complexity of today’s
purposes. He is in fact in a condition of vulnerability and clinical engineering and underlining that such a high level
weakness due on the one hand to his health condition and of complexity on the scene requires a director and a team
on the other to the fact that he is in a structure in which he that must work in perfect harmony and with the total ability
knows nothing: neither spaces, nor people, nor technology. to manage complexity.
The number of electro-medical devices that are nowadays In the second chapter we face very modern issues such
connected to the patient, physically or not, easily exceeds as the creation of open-source medical devices. This chap-
two dozen. Minor indecision from the operator can cause ter takes the reader to a little-known world, showing how
harm to the patient. A minimum breakdown can be very dan- collaborative design of open-source medical devices can
gerous. On the other hand, accurate planning of the entire enhance the access to medical technologies, thanks to a fea-
life cycle of a hospital’s technological equipment can make sible reduction in design, management, maintenance, and
life easier for operators and can have a fantastic positive im- repairing costs.
pact on patients themselves and on the whole process. The third chapter provides a very long list of success
The conductor of this orchestra is the clinical engineer, stories from hundreds of clinical engineers from around the
who must have the right skills to understand when it is time world. The idea was born in Hangzhou China, in October
to turn to the pianist, when to the drummer, when to the gui- 2015, where the world’s leading experts gathered to devise
tarist, and when to all the instrumentalists together. Unlike a path to promote clinical engineering in the world. On the
what happens in a common musical orchestra, however, the occasion of the first Global Clinical Engineering Summit,
musicians in this case do not all speak the well-coded lan- we realized how much need there was to let a wide audience
guage of music, but they can use very different languages. A know what clinical engineers do for the benefit of the com-
medical device manufacturer, a manager, a patient, a doctor, munity. As a result, we collected hundreds of success stories
a technician, and an economist have extremely different cul- from 125 different countries! In this chapter many of them
tural and linguistic backgrounds. The clinical engineer has are listed and properly linked.

1
2 SECTION | 1 Clinical engineering

This section provides a complete overview of the use into the procurement process management of innovative
of RFID (radio-frequency identification) technologies in medical technologies, close this rich section of the Clinical
the health sector. Two focuses: one showing how computer- Engineering Handbook.
aided facility management relates to the profession of to- Enjoy the reading!
day’s clinical engineers and the other providing deep insight
Chapter 1

Clinical engineering
Ernesto Iadanza
IFMBE HTA Division, School of Engineering, University of Florence, Florence, Italy

Medicine core tasks, such as diagnosis and therapy, have Actually a general and simple definition of clinical en-
always been intimately linked to using tools ranging from gineering could be the application of engineering skills
stethoscopes to plasters and gauzes. Today’s medicine is and methodologies and approach for the benefit of the
grounded on the use of a huge amount of these tools called patient.
medical devices. The simplest stethoscopes, plasters, and Over the years some organizations have provided their
gauzes are still there, but they are now in the good com- definition for “clinical engineer,” reflecting their vision.
pany of the most cutting-edge technologies. Not a single Among them, the American College of Clinical Engineers
activity in today’s modern healthcare setting would be pos- (ACCE) in 1992 provided the following definition:
sible without making use of dozens of pieces of equipment,
A Clinical Engineer is a professional who supports and ad-
both hardware and software. This brings a whole new set
vances patient care by applying engineering and managerial
of ­exciting possibilities. Nevertheless, such a high level of
skills to healthcare technology.
complexity on the scene requires a director and a team that
must work in perfect harmony and with the total ability to (American College of Clinical Engineering, 2019)
manage complexity. To quote Uncle Ben (yes, Spider-Man’s
A broader definition was provided at the first Global
uncle): “with great power comes great responsibility!”
Clinical Engineering Summit (Hangzhou, China, October
23, 2015) where 36 representatives from national and in-
What is clinical engineering? ternational societies convened. As a result of that summit,
a document has been outlined to define the main activities
Since words are important, a quick online search on the
describing biomedical engineers and clinical engineers. The
Online Etymology Dictionary for the word “clinical” brings
clinical engineer was described as
us to this result:
A professional who is qualified by education and/or registra-
clinical (adj.)
tion to practice engineering in the health-care environment
1780, “pertaining to hospital patients or hospital care,” from
where technology is created, deployed, taught, regulated,
clinic + -al (2). […]
managed, or maintained related to health services. Other
(Online Etymology Dictionary, 2019) related terms used for the CE role in developing countries
include biomedical engineer, and rehabilitation engineer.
If we carry on searching for “clinic” on the same dic-
tionary, this is the result: (IFMBE/CED Definitions, 2019)

clinic (n.) The World Health Organization (WHO) noted in 2018

1620s, “bedridden person, one confined to his bed by sick- that it is critical that “trained and qualified medical engi-
ness,” from French clinique (17c.), from Latin clinicus “phy- neering professionals are required to design, evaluate, regu-
sician that visits patients in their beds,” from Greek klinike late, maintain, and manage medical devices, and train on
(techne) “(practice) at the sickbed,” from klinikos “of the their safe use in health systems around the world. This role
bed,” from kline “bed, couch, that on which one lies,” from is referred to as clinical engineering (CE), biomedical en-
suffixed form of PIE root *klei- “to lean.” gineering (BE), and/or healthcare technology management
(HTM) dependent on regional terminology.” WHO often
(Online Etymology Dictionary, 2019)
uses the term “biomedical engineer” as one who practices
Therefore, the concept of leaning on the patient is clinical engineering (IFMBE/CED CE-HTM Definitions,
embedded in the actual “clinical engineering” locution. 2019).

Clinical Engineering Handbook. https://doi.org/10.1016/B978-0-12-813467-2.00001-8

Copyright © 2020 Elsevier Inc. All rights reserved. 3
4 SECTION | 1 Clinical engineering

In the first edition of the same book, Joseph D. Bronzino • Field service support
provided the following list of some typical pursuits, that is • Security/privacy/cybersecurity
still valid: • Forensic engineering/investigation
• Manufacturing practices such as QMS (quality manage-
• Supervision of a hospital clinical engineering depart-
ment system), GMP (good manufacturing practice)
ment that includes clinical engineers and biomedical
• Medical imaging
equipment technicians (BMETs)
• Project management
• Prepurchase evaluation and planning for new medical
• Robotics
technology
• Virtual environments
• Design, modification, or repair of sophisticated medical
• Risk management
instruments or systems
• EMI (electromagnetic interference)/EMC (electromag-
• Cost-effective management of a medical equipment cal-
netic compatibility) compliance
ibration and repair service
• Technology innovation strategies
• Safety and performance testing of medical equipment
• Population- and community-based needs assessment
by BMETs
• Engineering asset management
• Inspection of all incoming equipment (new and return-
• Environmental health
ing repairs)
• Systems science
• Establishment of performance benchmarks for all
equipment This list, far from wanting to be exhaustive of all the
• Medical equipment inventory control possible topics, gives quite an impressive idea—if read to-
• Coordination of outside services and vendors gether with the previous one—of how quickly the role of the
• Training of medical personnel for the safe and effective clinical engineer is expanding. Today’s clinical engineers
use of medical devices and systems must face a dramatically increased set of scenarios, compe-
• Clinical application engineering, such as custom modi- tences, and skills. Agreeing that this cannot be a task for a
fication of medical devices for clinical research or eval- single professional, the clinical engineer is today asked to
uation of new noninvasive monitoring systems be a capable and competent manager of a larger and larger
• Biomedical computer support team of collaborators and professionals.
• Input to the design of clinical facilities where medical
technology is used [e.g., operating rooms (ORs) or in-
tensive care units] Fields of knowledge
• Development and implementation of documentation
Section VII in this book treats the subject of education
protocols required by external accreditation and licens-
exhaustively. Here the syllabus of two Master’s Degrees
ing agencies (Bronzino, 2004)
in Clinical Engineering, designed by the author for the
On the occasion of the aforementioned first Global University of Florence, is just briefly reported. For a better
Clinical Engineering Summit (Hangzhou, China, October comprehension it is worth explaining that “first level mas-
23, 2015), a document has been outlined to define the ter” refers to a 1-year program for graduates with a 3-year
main activities describing biomedical engineers and clini- degree, while “second level master” refers to a 1-year pro-
cal engineers. In that document, as described by Iadanza gram for postgraduate candidates holding a 5-year laurea
(2018), there is quite a long list of subtopics of biomedical degree.
engineering, listed as “Application and operation: Clinical First level master in clinical engineering
Engineering” and reported here:
• Fundamentals of bioengineering
• Technology management • Fundamentals of clinical engineering
• Quality and regulatory assurance • General and organizational models
• Education and training • Audits and technology management
• Ethics committee and clinical trials • Evaluate technologies and systems
• Disaster preparedness • Medical devices, software, and systems
• e-health (telemedicine, m-health) • Electrical medical systems
• Wearable sensors/products • Elements of instrumentation and biomedical technologies
• Health economics • Biomedical instrumentation
• Health systems engineering • Systems diagnostic imaging
• Health technology assessment/evaluation • Innovative applications
• Health informatics • Management tools
• Service delivery management • Wireless systems
 Clinical engineering Chapter | 1 5

Service General For example, if it is true that computer support in terms

HTM delivery management of maintenance does certainly not become a regular part
management
of clinical engineers’ duties (with some exceptions), it is
Risk
Education of
management CE-IT also certainly true that there is almost no piece of medi-
others /safety cal equipment that does not embed a computer, today. In
that sense, clinical engineers are managing the whole life
Testing, Disaster
Facilities
evaluation, cycle of these “computers!” Moreover, all kinds of mobile
management preparedness
modification devices and apps are currently used by healthcare personnel
for managing every aspect of their profession. Managing
HTA Lean thinking
such complex processes will be daily bread for the clinical
Quality
engineers of tomorrow.
Let us continue our journey back in time and read what
Bronzino said about telecommunications: “Hospitals are
Procurement Mobile apps Models also making increased use of facsimile (fax) transmission.
This equipment allows documents, such as patient charts,
to be sent via telephone line from a remote location and re-
FIG. 1 Some of the fields of knowledge involving clinical engineering.
constructed at the receiving site in a matter of minutes. […]
Some newer equipment allows pictorial information, such
Second level master as patient slides, to be digitally transmitted via a phone
• General and organizational models line and then electronically reassembled to produce a video
• Organization of health systems and regional models image” (Bronzino, 2004). Well, knowing what happened
• Planning, monitoring, and evaluation of performance since then puts a smile on our face. Our future readers will
• Human resource management definitely have the same smile reading the description of
• Economic and financial instruments in health care today’s virtual/augmented reality applications in surgery,
• Project management in health care the current three-dimensional (3D) printing facilities, and
• Principles and methods of Health Technology Assessment the brand new 5G (fifth-generation) networks. One thing is
(HTA) sure: safe and powerful telecommunications infrastructures
• Methodology, research, and review are today (and will be more and more) as necessary for hos-
• Technical, economic, and social aspects pitals as water for human beings.
• Design, innovation, and sustainability Similar considerations can be made for facilities
• Legal aspects of clinical engineering ­operations and strategic planning. The modern hospitals
• Data management and information are designed using the most advanced Building Information
• Health information systems Modeling (BIM) tools, providing a 3D virtual model of the
• Telematics, telemedicine, and health services in the area whole structure, including the plants (e.g., medical gasses)
and the embedded technologies. These systems have already
Fig. 1 summarizes just some of the fields in which to- become everyday tools to effectively manage all kinds of
day’s clinical engineers are involved. healthcare activities, including clinical engineering services.
New approaches are continuously appearing on the scene
New challenges of clinical engineering, a discipline in continuous evolution.
Planning the maintenance based on real evidence (Evidence
As an exercise, let us go back about 15 years and read Based Maintenance, EBM) has started to become a real-
again what Bronzino identified as topics for the “Future of ity in some facilities (Gonnelli et al., 2018; Iadanza et al.,
Clinical Engineering” at the end of his chapter “Clinical 2019). The growing availability of big data, the interoper-
Engineering: Evolution of a Discipline” in the first edition ability of systems as well as the rapid diffusion of machine
of his book (Bronzino, 2004): learning and deep learning techniques will certainly provide
• Computer support the clinical engineers of the future with new sophisticated
• Telecommunications approaches and techniques.
• Facilities operations
• Strategic planning References
Well, maybe not surprisingly, nowadays the above list American College of Clinical Engineering, 2019. Retrieved from: https://
of topics forms a good part of the core services provided by accenet.org/about/Pages/ClinicalEngineer.aspx.
clinical engineering departments all over the world, maybe Bronzino, J.D., 2004. Clinical engineering: evolution of a discipline.
not in the sense that was conceived back in 2004, but it is. In: Dyro, J.F. (Ed.), Biomedical Engineering, Clinical Engineering
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Handbook. Academic Press, ISBN: 9780122265709, pp. 3–7. https:// test procedure, risk analysis, and technical solution. Proc. IEEE 98 (9),
doi.org/10.1016/B978-012226570-9/50003-X. http://www.sciencedi- art. no. 5508336, 1656–1662.
rect.com/science/article/pii/B978012226570950003X. Iadanza, E., Marzi, L., Dori, F., Gentili, G.B., Torricelli, M.C., 2007.
Gonnelli, V., Satta, F., Frosini, F., Iadanza, E., 2018. Evidence-based ap- Hospital health care offer. A monitoring multidisciplinar approach. In:
proach to medical equipment maintenance monitoring. In: IFMBE IFMBE Proceedings, vol. 14 (1), pp. 3685–3688.
Proceedings, vol. 65. Springer, Singapore. Iadanza, E., Dori, F., Miniati, R., Corrado, E., 2010. Electromagnetic in-
Iadanza, E., 2018. IFMBE/Clinical Engineering Division projects for the terferences (EMI) from active RFId on critical care equipment. In:
advancement of the profession of clinical engineering. In: IFMBE IFMBE Proceedings. 29, pp. 991–994.
Proceedings, vol. 65. Springer, Singapore. Iadanza, E., Baroncelli, L., Manetti, A., Dori, F., Miniati, R., Gentili, G.B.,
Iadanza, E., Gonnelli, V., Satta, F., Gherardelli, M., 2019. Evidence-based 2011. An rFId Smart container to perform drugs administration reduc-
medical equipment management: a convenient implementation. Med. ing adverse drug events. In: IFMBE Proceedings, vol. 37, pp. 679–682.
Biol. Eng. Comput. https://doi.org/10.1007/s11517-019-02021-x. Iadanza, E., Chini, M., Marini, F., 2013. Electromagnetic compatibility:
IFMBE/CED CE-HTM Definitions, 2019. Retrieved from: https://ced.if- RFID and medical equipment in hospitals. In: IFMBE Proceedings,
mbe.org/resources/ce-htm-definitions.html. vol. 39. IFMBE, pp. 732–735.
IFMBE/CED Definitions, 2019. Retrieved from: http://cedglobal.org/ Luschi, A., Belardinelli, A., Marzi, L., Frosini, F., Miniati, R., Iadanza,
definitions/. E., 2014a. Careggi Smart hospital: a mobile app for patients, citizens
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pp. 125–128.
Luschi, A., Marzi, L., Miniati, R., Iadanza, E., 2014b. A custom decision-
Further reading support information system for structural and technological analysis in
Badnjevic, A., Gurbeta, L., Jimenez, E.R., Iadanza, E., 2017. Testing of healthcare. In: IFMBE Proceedings, vol. 41, pp. 1350–1353.
mechanical ventilators and infant incubators in healthcare institutions. Miniati, R., Dori, F., Iadanza, E., Fregonara, M.M., Gentili, G.B., 2011.
Technol. Health Care 25 (2), 237–250. Health technology management: a database analysis as support of
Biffi Gentili, G., Dori, F., Iadanza, E., 2010. Dual-frequency active RFID technology managers in hospitals. Technol. Health Care 19 (6),
solution for tracking patients in a children’s hospital. Design method, 445–454.
Chapter 2

Open-source medical devices:

Healthcare solutions for low-,
middle-, and high-resource
settings
Carmelo De Mariaa, Licia Di Pietroa, Alice Ravizzab, Andres Diaz Lantadac,
Arti Devi Ahluwaliaa
a
Research Center E. Piaggio and Department of Information Engineering, University of Pisa, Pisa, Italy,
b
Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy, cDepartment of
Mechanical Engineering, Universidad Politécnica de Madrid, Madrid, Spain

Increasing the access to medical devices: l­ ow-income countries more than 80% of medical equipment
The need for alternative strategies for is donated, but only 10%–30% of these become operational,
given the high operating cost, the lack of personnel, and the
innovation frequent failures due to harsh environment, extreme climate
Medical technology is one of the pillars of an effective conditions, humidity, dust, and power instability (Steinberg
healthcare system, as recognized by the United Nations et al., 2015; World Health Organization, 2010a,b; Iadanza
Member States in the 2030 Agenda for Sustainable and Dyro, 2004; Malkin, 2007; Lustick and Zaman, 2011).
Development Goals (SDGs) (UN, 2019), which strives These conditions are usually not taken into account during
for the achievement of inclusive and sustainable develop- the design phase causing more frequent failures and deter-
ment, drawn on the principle of “leaving no one behind.” mining a higher request for spare parts, which are expensive
Furthermore, increasing the access to medical devices and difficult to find, making maintenance and repairing as
(MDs) has been included by the World Health Organization problematic as acquisition (Malkin, 2007).
(WHO) as one of the six leadership priorities to promote Developing sustainable medical technologies to make
health throughout the whole lifetime. health care affordable to a larger population, and thus re-
However, the overall high costs of MDs create a barrier ducing global inequalities, can only be performed taking
for achieving this target. The necessity to guarantee efficacy into account the cultural, socioeconomic context, and the
of the device and safety for patients, healthcare providers, ­environment-climate constraints in which these will be applied
bystanders and, in the broader view, the health and thus (Malkin, 2007; Lustick and Zaman, 2011; Douglas, 2011).
the wealth of a country (Lissel et al., 2016) has brought to However, in many cases patients’ or medical profession-
strict norms and to control each step of the long life cycle als’ needs are considered as a minor part of the decision-
of a MD (design, prototyping, manufacturing, labeling and making process and, under the pressure of marketing and
packaging, provision, installation, operation, maintenance, immediate payback, often clinical needs of rare pathologies
repair and disposal). This “safety by design” and the qual- and of low-resource settings are left unattended (Fasterholdt
ity control determine a higher production cost. It has been et al., 2018).
estimated that developing a MD from the idea to the mar- In contrast with the biomedical industry, many product
ket has a cost of around $31 million for a low-to-moderate- fields have experienced a paradigm shift from a “close” to
risk device, and around $94 million for high-risk products an “open innovation,” by now involving often stakehold-
(Steinberg et al., 2015). ers and future users since the beginning of the product de-
Removing the charge on a single step could not make velopment process (Ng and Jee, 2014; Gao and Bernard,
the difference. For example, the WHO estimates that in 2017).

Clinical Engineering Handbook. https://doi.org/10.1016/B978-0-12-813467-2.00002-X

Copyright © 2020 Elsevier Inc. All rights reserved. 7
8 SECTION | 1 Clinical engineering

Thanks to the web and the social networking, with the on the web (Niezen et al., 2016); however only some of
support of cloud-based design and prototyping (Wu et al., them have been designed to be compliant with MD legisla-
2015), this new approach of social product development tion (GammaCardioSoft S.r.l., 2019; Ferretti et al., 2017;
has taken place, with the creation of virtual communities Arcarisi et al., 2019) (Fig. 1).
that actively develop innovative solutions (Perilli, 2017; Open-source medical devices (OSMDs) and their
Sarmah and Rahman, 2017), freely shared on online reposi- boundaries should be adequately defined, to have a real im-
tories, such as Thingiverse or GrabCAD, born in the wake pact on the medical industry and healthcare systems. In the
of the “Makers” movement (Gershenfeld, 2005; Rosenfeld following sections, a reasoned definition of OSMD is pro-
Halverson and Sheridan, 2014). posed, and the underlying enabling technologies and sup-
Indeed, the benefit of collaborative and open-source de- porting practices are provided.
sign, in terms accessibility, sustainability, lower costs, im-
proved performance, and safety, has been widely exploited Open-source medical device definition
in software development (Lessig et al., 2005) and is under
consideration also in the academic research in several fields The construction of the OSMDs definition is based on the
from biology to nanotechnology (Oberloier and Pearce, currently recognized statement on MD endorsed by WHO
2018; Mushtaq and Pearce, 2018). (World Health Organization, 2019) and on the successful ex-
However, more safety and security-sensitive fields, in- amples of the open-source software (Open Source Initiative,
cluding health care, are still reluctant to taking advantage of 2019) and hardware movements (Open Source Hardware
the enormous potentials of open-source and collaborative Association, 2019), and on the principles expressed in the
approach toward a social development of MDs, although it Kahawa Declaration (Ahluwalia et al., 2018a), a manifesto
has the potential to increase the access to medical technolo- for the democratization of medical technologies, signed by
gies, thanks to a feasible reduction in design, management, representatives of biomedical engineering (BME) commu-
maintenance, and repairing costs, due to the open access nity in Europe and Africa.
to device blueprints (De Maria et al., 2018). In the medi-
cal industry, it is crucial to ensure the safety and efficacy
Medical device
requirements of medical technology and for this reason the
adoption of open resources must follow the standards and According to the International Medical Device Regulators
the current regulations (DeMaria et al., 2015). Several ex- Forum (IMDRF) [ref] and recognized by WHO (World
amples of healthcare-related technologies have appeared Health Organization, 2019), “Medical device means any

(A)
HV-board Internal
Charging
power Capacitor H-bridge discharge
circuit
supply Inner Selector
circuit

Connector Connector
Battery Patient
Outer Selector
High-voltage Board

PSOC
C-board
power I/O
supply
Control Board

(B) (C)
FIG. 1 Examples of open-source medical devices: Prosthetic hand (e-NABLE Community, 2019) (A); Device for breast self-examination (Arcarisi
et al., 2019) (B); schematic of an open-source automatic external defibrillator compliant to standards (C) (Ferretti et al., 2017).
 Open-source medical devices Chapter | 2 9

instrument, apparatus, implement, machine, appliance, im- i­nfrastructure, unrestricted content, and open-source de-
plant, in vitro reagent, software, material or other similar sign tools to maximize the ability of individuals to make and
or related article: a) intended by the manufacturer to be use hardware. Open source hardware gives people the free-
used, alone or in combination, for human beings for one or dom to control their technology while sharing knowledge
more of the specific purpose(s) of: diagnosis, prevention, and encouraging commerce through the open exchange of
monitoring, treatment or alleviation of disease; diagno- designs” (Open Source Hardware Association, 2019).
sis, monitoring, treatment, alleviation of or compensation The definition is based on the previously mentioned
for an injury; investigation, replacement, modification, or open-source definition for open-source software. However,
support of the anatomy or of a physiological process; sup- as hardware differs from software by requiring the use of
porting or sustaining life; control of conception; disinfec- physical resources for the creation of physical goods, it
tion of medical devices; providing information for medical is important to highlight that these principles and defini-
or diagnostic purposes by means of in vitro examination of tion of OSHW also state that “persons or companies pro-
specimens derived from the human body; and b) which does ducing items (“products”) under an OSHW license have
not achieve its primary intended action in or on the human an obligation to make it clear that such products are not
body by pharmacological, immunological or metabolic manufactured, sold, warranted, or otherwise sanctioned by
means, but which may be assisted in its intended function the original designer and also not to make use of any trade-
by such means.” marks owned by the original designer.”
Consequently, MDs range from contact lenses to band-
aids, from pacemakers to implantable heart valves, from sur-
gical instruments to large medical imaging equipment. For Open-source medical devices
operative purposes, this definition covers also most MDs Based on these three definitions we have articulated a new
worldwide, as defined many regulatory bodies, such as the definition for OSMDs, but in a way combines and expands
EU Parliament (EUR-Lex, 2019), the US Food and Drug them, in order to account for very specific and relevant is-
Administration (Food and Drug Administration, 2019), or sues present in medical technology development, for the
the Chinese Food and Drug Administration (Sun, 2012). fact that modern MDs involve hardware and software, and
for adequately incorporating recent trends in data manage-
ment in collaborative projects (Wilkinson et al., 2016).
Open-source software
Thus, according to our proposed definition, an OSMD is
The most commonly used definition of open-source software “a medical device whose design and product development
(currently the open-source definition v.1.9 (Open Source information are made publicly available so that anyone can
Initiative, 2019)) derives from the Debian Free Software study, modify, distribute, make, and sell the medical devices,
Guidelines created by Bruce Perens and the Debian develop- and their related software or hardware, based on the initial
ers (Perens, 1999; Debian, 2019). In short, open-source soft- available design and information. The design of the open
ware is software with accessible source code, hence allowing source medical device should be shared in a format con-
peer-review and rapid evolution, complying also with criteria ceived for enabling validation, verification and modifica-
such as: free distribution, distribution in source and compiled tion. Open source medical devices rely on widely available
code, allowance of modifications and derived works, lack of materials and components, benefit from being designed
discrimination against specific persons or groups, lack of dis- according to international safety standards and processes
crimination against fields of use, lack of restriction to other aimed at guaranteeing patients’ safety, take advantage of
software, lack of product specificity, and technological neu- modularity, even being designed as inter-changeable and
trality. Examples of open-source software licenses include inter-operable kits, and rely on open e-infrastructures for
“GPL,” “BSD,” and “Artistic,” among others. information dissemination and promotion of collaboration.
FAIR (findable, accessible, interoperable, reusable) data
principles are proposed for open source medical devices.
Open-source hardware Persons or companies producing and commercializing open
The open-source hardware association (OSHWA) defines source medical devices are obliged to attribute to the origi-
open-source hardware in its Statement of Principles 1.0 and nal designers and to make clear that such medical devices
Definition 1.0 as: “hardware whose design is made pub- are not manufactured, sold, warranted, or otherwise sanc-
licly available so that anyone can study, modify, distribute, tioned by the original designer.”
make, and sell the design or hardware based on that design.
The hardware’s source, the design from which it is made, is
available in the preferred format for making modifications
Enabling tools and technologies
to it. Ideally, open source hardware uses readily-­available Design activities normally require the use of computer-
components and materials, standard processes, open aided design (CAD) and simulation software tools, as
10 SECTION | 1 Clinical engineering

well as the access to prototyping facilities. In these com- Mobile-based technologies

plete development cycles, the manufacturing and testing
stages help to detect design problems and lead to rede- Another great enabler for pursuing the above-mentioned
sign cycles, as happens with standard product design and health priorities is m-health, which relies on the wide-
development. spread diffusion of smartphones in developing countries.
Creating an OSMD requires not only the aforemen- In LRSs this kind of technology has been exponentially
tioned tools but also interdisciplinary interactions be- increasing in the past few years: 28% of people in Kenya
tween MD designers, healthcare professionals, patients, with secondary-level or higher education now own a
citizens, and policy makers. Collaborative research and smartphone, and 88% of Nairobi medical students do too
development online environments, capable of enabling (Edgcombe et al., 2016). Many MDs can be substituted by
collaboration, helping to match medical needs and tech- a smartphone (Kassianos et al., 2015), by the joint use of a
nological offers, is the specific framework for boost- smartphone and 3D printed add-ons (Myung et al., 2014;
ing this process, as the coordination of multiple actors Bastawrous et al., 2016).
is crucial to the transformation of an invention into an
economically advantageous and marketable innovation Electronic rapid prototyping
(Bonaccorsi and Rossi, 2003).
Open-source electronic rapid prototyping boards have had
a strong influence on product development, providing a
Open-source design and simulation tools quick path from prototype to production. Platform such
Open-source design software is an appropriate alternative as Arduino (Arduino, 2019) or BeagleBone (Beagleboard,
for dramatically reducing the operational costs for codesign 2019) paved the way to cases of success in the OSMD field,
MDs. FreeCAD (FreeCADweb, 2019) and OpenSCAD already on the market, include: open-source electronic kits
(OpenSCAD, 2019) provide interesting examples of this for medical signals, such as the solutions by Bitalino (Alves
open approach to CAD software, successfully used in several et al., 2006) and Proto Central Electronics (Withchurch,
nonmedical open-source projects (Open Source Ecology, 2019), open-source ECG systems (GammaCardioSoft S.r.l.,
2019). Open options are also available for performing sim- 2019).
ulations linked to a wide set of engineering problems, for
example, the finite-element modeling open solutions, such Virtual platforms
as Code Aster (Code Aster, 2019), or ELMER (CSC, 2019).
The relevance of OSMDs has been already put forward
by inspiring projects and has achieved very interesting re-
Accessible additive manufacturing sults demonstrating their transformative potential (see next
Additive manufacturing (well known as 3D printing) has section).
been identified as appropriate technology for many devel- Taking examples from open-source software commu-
oping countries: given their increased accuracy and repro- nities and requiring the coordination of a large number
ducibility, their ability to automatically fabricate functional of developers, these collaborative projects usually rely on
or geometrical complex objects, to print with different ma- well-consolidated versioning systems, such as Git-Hub
terials at the same time, 3D printing technologies could be (Git-Hub, 2019), and, less frequently, on project manage-
used to produce and customize MDs (Zadpoor and Malda, ment software. Several times these initiatives, projects,
2017). and enlarged communities have their own website for
This “3D printing revolution” in health care can bring sharing blueprints, but the upload of CAD files on “gen-
MDs, as surgery tools and orthosis, in low-resources set- eral purpose” showcase/repositories such as Thingiverse,
tings, but at the moment the quality control in the produc- GrabCAD, MyMiniFactory, and YouImagine is also com-
tion is an issue, even in high-income countries, and it has mon (Thingiverse, 2019).
to involve different actors, including printers and materials In this context, the UBORA e-infrastructure (Ahluwalia
manufacturers, healthcare providers and lab technicians, et al., 2018b; UBORA, 2019) promotes and sustains the
and policy makers. open-source development of MD by providing to a struc-
The widespread of low-cost 3D printers (usually based tured framework, inspired by MDR 2017/745 and the ISO
on fused deposition modeling technology) has made the standard 13485, for needs identification, risk class and rel-
regulation and standardization of this field even more ur- evant standards identification, project management, and
gent. There are several examples of 3D printed prosthetic documentation finalized preparation of the preproduction
hands, based on open-source files freely downloadable device dossier. Each stage is vetted and monitored by ex-
from the web (NIH, 2019), but their design and/or fabrica- perts to ensure that safety criteria are met during the design
tion are questionable. process (Fig. 2).
 Open-source medical devices Chapter | 2 11

FIG. 2 UBORA e-infrastructure: (A) landing page, and (B) some examples of medical device projects, selected through specific keywords.

The importance of human capital in instrumental for the realization of the first OSMDs b­ efore
their economic exploitation could be envisioned. This sec-
OSMDs tion describes the importance of human capital in the de-
The commitment and skills of single developers, as well velopment of OSMDs and highlights the role universities
as the strength of a supporting community, have revealed in nurturing a new generation of biomedical engineers.
12 SECTION | 1 Clinical engineering

Online communities and initiatives Perspectives

Inspiring pioneers have devoted themselves to explaining Open innovations have the potential to reshape the biomedi-
how to arrange “Do It Yourself” (DIY) labs for prototyp- cal industry in the next decade by letting patients, patient
ing (Pearce, 2014) and detailed in an open-source way associations, healthcare professionals, and technology de-
the development of several solutions, such as adaptive velopers play more relevant roles in the planning, specifica-
aids for arthritis patients or printable clubfoot bracer for tion, and conception of innovative healthcare technologies.
children (Gallup et al., 2018; Savonen et al., 2019), while The collaborative design, empowered by additive manu-
highlighting the potentials of distributed manufacturing facturing technologies already proved technically and eco-
to make MDs reach those who need them most and ana- nomically viable regardless of the size of production series,
lyzing the suitable business models for open hardware will promote the development of patient-specific devices,
(Pearce, 2017). including a special focus on rare pathologies, with a shift
Inspiring communities, aimed at promoting OSMDs from mass production to mass personalization. The needs
and sharing of information for improved medical technol- of remote and rural populations will be more adequately ad-
ogy and health care, can also be mentioned due to their re- dressed and answered, thanks to innovative supply chains
markable growth and international projection, such as the that may delocalize the production of OSMDs, placing the
“Enabling the Future” initiatives, focused on personalized fabrication facilities in the point of care.
prostheses designs for children; the “Patient Innovation” However, several challenges need to be faced and
networks, focused on shared information for solving com- solved in a collaborative way, for supporting the growth of
plex pathologies; the “Open Prosthetics” initiative and the the OSMD sector. Relevant questions linked to regulation,
“Open Bionics” environment, both concentrated on low- privacy, safety, traceability, intellectual property, sustain-
cost personalized prostheses (Pearce, 2017; e-NABLE ability, and policy making, among others, still require to be
Community, 2019; Oliveira et al., 2019; Open Prosthetics, understood (and their reliability demonstrated to a larger
2019; Open Bionics, 2019). scale) in this new paradigm of MD development.
In this direction, initiatives such as the UBORA
e-infrastructure and related international and multidis-
­
Changing the paradigm in biomedical ciplinary communities may turn out to be truly transfor-
engineering education mative resources for supporting the endeavors toward a
BME requires multidisciplinary collaborations to promote well-founded future for BME, which will be more open,
holistic approaches, so as to more effectively address pa- collaborative, and equitable.
tients’ needs and to adequately support medical profession-
als in their daily practice. Acknowledgments
In such context, collaborative project/problem-based
This project has received funding from the European Union’s Horizon
teaching-learning methods have been suggested as effec-
2020 research and innovation programme under grant agreement No.
tive strategies for bridging technical competences with 731053.
the development of transversal skills (Dochy et al., 2003;
Mahendru and Mahindru, 2011; Brennan et al., 2013)
and maybe invaluable in the education of BME students References
(Ahluwalia et al., 2018b). Ahluwalia, A., Maria, C.D., Díaz Lantada, A., 2018a. The Kahawa
The CDIO Initiative (CDIO, 2019) has been considered Declaration: a manifesto for the democratization of medical technol-
among the more relevant international proposals promoting ogy. Global Health Innov. 1 (1), 1–4.
project-based learning (PBL) methodologies worldwide. It Ahluwalia, A., María, C.D., Diaz Lantada, A., Madete, J., Makobore, P.N.,
is focused on the establishment of an innovative educational Ravizza, A., … Torop, J., 2018b. Biomedical engineering project
framework for producing the “engineers of the future,” by based learning: Euro-African design school focused on medical de-
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engineering fundamentals through “Conceiving-Designing- Alves, A.P., Da Silva, H.P., Lourenco, A., Fred, A.L.N., 2006. BITalino:
a biosignal system acquisition based on Arduino. In: Proceeding
Implementing-Operating” (CDIO) real-world systems,
of the 6th Conference on Biomedical Electronics and Devices
processes, and products (Crawley et al., 2007). As regards
(BIODEVICES).
BME, CDIO experiences in which students live through the Arcarisi, L., Di Pietro, L., Carbonaro, N., Tognetti, A., Ahluwalia, A.,
complete development of MDs, have been recently devel- De Maria, C., 2019. Palpreast-a new wearable device for breast
oped with success, both with undergraduate and graduate ­self-examination. Appl. Sci. 9, 381.
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Discovering Diverse Content Through
Random Scribd Documents
20, Fazakerlcy street, Ac 6, Smithdown lane Copeman Charles
Richard, attorney, (Snowball £ C.) 24, Upper Canning street Corey
Charles, dentist, (C. £ Newman.) 5, Slater street Cottrell Joseph,
metal im-cht. (Jones £ C.) 14, Kingst. Edge hill Counihan John J.
wine and spirit merchant, (C., Murphy £ Co.) 102, Mount pleasant
Matthew, wine and spirit merchant, (C., Murphy and Co.) 102, Mount
pleasant , Mtirphy As Co. distillery, brewery, A: wine agents. At
commis. mrchts. 10, Exchange bdgs t wine and spirit and family ale
and porter bottlers, 100, Mount pleasant Cowen Thomas, gardener
Ai florist, 69, Cornwall st. Evertou Craig John and Co. merchants,
and importers of American brooms, woodenware, Aic. 10, Stanley
street Robert, wine and spirit merchant and victualler, Abbotsford
Hotel, Victoria road, Seacombe Craper and Janaway, toy dealers, 6,
Great Charlotte street Robert, toy dealer, (C. £ Janaway,) 6, Gt.
Charlotte st Crompton James, commission, estate Ai house agent, &
district manager of the English Widows’ Life Assurance Fund, 8,
Prince’s terrace, Grange lane, Birkenhead ; office, 16, South John
street — See A dvt Thomas, warehouseman, 207, Park road Crouch
William, victualler. The Fox, 20, Cable street Gumming Anthony,
merchant, Albert villa, Huy ton office, 34, Castle street Cummins
Gilbert, gentleman. Craven terrace, 245, Upper Parliament street
DAVIES Margaret Jane, 9, Mere lane, Walton Reuben Wright, book
keeper, 8, College street East Thomas, lodging house, 12, Cornwallis
street Davis Elizabeth, CO, Falkner street Day Joseph, jun. and Co.
ship brokers, Washington buildings Dean John, accountant, 74,
Phythian street, Low hill J. victualler, Crapes Inn, 139, Great Hoiner
street Dickinson James, lodging house, 7, Cornwallis street Dobson
Emma, hay arid straw dealer, 63, Newsham street James, carpet and
blanket cleansing, preserving and restoring works. Brack road,
Everton — See Advt Dodd Thomas, glass merchant, Grant road,
Knotty Ash and Co. glass, lead At oil merchants, 64, Dale st Thomas,
jun. glass mrchnt. (Thos. D. £ Co.) Egrcinont Donnolly Rev. Michael,
(St. Vincent de Paul’s,) 13, Hardy st Duff James Campbell, cashier,
22, Pine street DUKE-ST. JOINT STOCK LOAN ASSOCIATION,
(Edward Jones, agent,) 98, Duke street — See Advt Dumbell George,
book keeper, 58, Breckfield road South John, insurance surveyor, 41,
Stafford street
 4 ELKIN GT ON AND COMPANY, CHURCH STREET,
LIVERPOOL, INVENTORS AND PATENTEES OF TIE ELECTRO PLATE,
MANUFACTURING SILVERSMITHS, FINE ART BRONZISTS, Ifequest
(Parties intentding to pujr6ha.se Jirtioles of their J/Lanufo.cture to
satisfy themselves that their JVEarhs ||| are distinctly stam-ped on
every piece — such only being vuarranted by VLKIJ\TG-Q10J\[
The text on this page is estimated to be only 26.71%
accurate

LIVERPOOL STREET DIRECTORY, FOR TIIE BOROUGH AND

ENVIRONS, WITH A REFERENCE TO THEIR SITUATIONS. ABBEY
street, Church st. Birkenhead Abbott street, Church st. Birkenhead
Abercromby square, Oxford street \bercromby terrace, Oxford street
Aberdeen street. Park road Abstinence street, Mann st. Tox. park
Acre terrace, Everton brow Acrefield road, Much Woolton Acton
terrace, Bock Ferry Addison street, Marybone Adciaide buildings, 2,
Chapel street Adelaide buildings, Ranelagh place Adelaide street,
Nethefield road North Adelaide terrace, Waterloo Adelphi street,
Market st. Birkenhead Adlington street, Standish street H5tna street,
West side Queen’s Dock Hitna street, Green lane, Stanley Aigburth,
Aigburth road Aigburth hall road, Aigburth Aigburth Yoad, Park road
Aigburth street, Upper Parliament st Aigburth vale, Aigburth Aintree,
through Walton Aintree street. Doncaster street Albany The, 6,
Oldhall street Albert buildings, 29, CaDning place Albert Dock,
Saltkouse Dock Albert parade, Albert Dock Albert place, Old Chester
road, Tranmere Albert street, Paddington Albert street, Warwick st,
Tox. park Albert street, William Henry st. Everton Albert street,
Albion street, Birkenhead Albert terrace, New Brighton Albion
buildings, 14, Canning place Albion buildings, Chester st. Birkenhead
Albion chambers, l, Brunswick street Albion place, 28, Old
Haymarket Albion street, Gloucester street Albion street, Grecian
terrace, Everton Albion street. Bridge street, Birkenhead . Albion
street. New Brighton Albion terrace, Low hill Alcock buildings. Morley
st. Kirkdale Aldersey street, Wellington street Alfred place, Park road
Alfred road, Claughtonn Alfred street, Great George street Alice
street, Paddington Allerton, through Wavertreet Allerton lane,
Wavertree Allerton road, Much Woolton All Saints’ lane, Rose place
Alma bank , Frcn tonlanc, H igherTranmere Alma road, Mersey road,
Aigburth Alma street, Wcstbourne street Alma terrace, St. George’s
hill, Everton Alma terrace, Brighton street, Scacombe Alma vale,
Crosby village A Imond street, Myrtle street An. onrt terrace,
Wavertree road Ajmoida green. West Derby village Alton terrace.
Village road, Oxton Amazon tor. George’s rd. West Derby rd mber
street. Chatham street leha lane, Hew Ferry lane celia street, Rokeby
street, Everton nderson street, Great Homer street .nderson street.
Everton village Anneld, Walton breck infield road, Anfiekl Angela
street, Edge hill Anglesea terrace, West Derby road Ann street,
Salisbury street, Everton Anne street, Bedford street, Tox. park Anne
street. Mill road, Everton Ansdell street, Mersey street Anson place,
London road Anson stieet, London road Ansnn terrace, Anson street
Anthony street, Mellor street Back Chester st. Dexter st. Toxteth park
Back Church street, Egremont Back Clare street, Springfield street
Back Claremont street, Claremont grove Back College street, College
street Back Colquitt street. Seel street Back Commutation row,
Islington Apple grove, Well lane, Higher Tranmere Back Devon
street, Falkland street Apsley buildings, 4, Oldhall street Archer
terrace. 13, Smithdown lane Arden street, Scotland road Argyle
street, Hanover street Argyle stieet, Canning st. Birkenhead Arley
street, Vauxhall road Arno road, Oxton Arrad street, H ope street
Arrow street, Wavertree road Arthur street, Cleveland st. Birkenhead
Arthur street. South hill road Ascot street, Latimei street Ash street,
Wavertree road Ashbrook terrace,- Lower Bebbington Ashfield,
Wavertree road Ashfield road, Aigburth vale Ashfield street, Vauxhall
road Ash grove, Christopher st. Walton road Ash grove, Martin st.
West Derby road Ash grove, Wavertree Ashleigh, Walton breck
Ashley street, Erskine street Ashley street, Warwick st. Toxteth park
Ashton street, Pembroke place Ashton street, St, James place
Ashvillcroid, Birkenhead park Aspinall street. Sandhills lane Atherton
buildings, 23, Dale street Atherton street, South Castle street
Atherton street, Netherfield road North Atherton street. Grange lane.
Birkenhead Athol street, Great Howard street Atkinson street,
Mansfield street Audley street, London road Audley street, Everton
road Aughton street. Great Homer street Austin street, Grange lane,
Birkenhead Avon street. Sparling srreet, Everton BACHELOR street.
Dale street Backford terrace, West Derby road Back lane, Mill lane,
West'Derby Back lane, Prenton la. Higher Tranmere Back lane,
Walton village Back lane, Wallasey, Cheshire Back Almond street,
Almond street Back Ashton st. Ashton st. Pembroke pi Back Barton
street, Windsor Back Beau street, Fox street Back Beckwith
st.Victoriast. Birkenhead Back Bedford street N. Brownlow hill Back
Bedford street S. Cambridge street Back Berry street. Wood street
Back Bittern street, Pomona street Back P.lackbume street. Cypress
itreet Back Blake street, Warren street Back Blenheim street,
Blenheim street Back Bh om street, Bloom street Back Bold street,
Bold street Back P.oltou street, High street. Edge hill Back Bond
street, Limekiln lane Back Boundary street, Boundary street Back i
ridport street. Hotham street Back Canning street, Canning street
Back Canterbury st. Carver st. Everton Back Castle street, Morley-st.
Kirkdale Back Catharine street, Percy street Back Chatham street,
Peach street Back Eldon street, Eldon street Back Falkner street
North, Mona street Back Falkner street South. Sandonstreot Back Gill
street, Dansie street Back Gore street North, Hankin street Back
poree. Water street Back Grafton street, Grafton st. Tox. pk Back
Great Mersey street, Kirkdale road Back Grove street, Walnut street
Back High street, High street, Edge hill Back Huskisson street,
Huskisson street Back Irvine street, Irvine st. Edge hill Back Jackson
street. Heath st, Tox. park Back King street, King street, Edge hill
Back Knight street, Berry street Back Lans'downe place, Mere la.
Everton Back Leeds street, Leeds street Back Lime street, Elliot
street Back Lower Mersey view, North Shore Back Mansfield street,
Wakefield street Back Maryland street, Baltimore street Back Mason
street. Paddington Back Mill street, Upper Hamngtonstreet Back
Milton street, Scotland road Back Mona street, Mona street Back
Mount street, Pilgrim street Back Mulberry street. Myrtle street Back
Myers street, Siuithd own-lane Back Myrtle street, Myrtle street Back
Nelson street, Upper Pitt street Back Nile street, Iiathbone street
Back Oliver street, Argyle st. Birkenhead Back Oxford street. Mount
pleasant Back Parliament street. Rati) bone street Back Parliament
st. Bedford st. Tox. pk Back Peach street, Chatham street Back Percy
street, Percy street Back Pickop street, Vauxhall road Back Portland
street, Vauxhall road Back Portland street, South Tranmere Back
Price street, Price street, Birkenkd Back Queen Anne street,
Wakefield street Back Ratbbone street, Rathbone street Back
Renshaw street, Oldham street Back Roe street, Roe street Back
Roscommon street. Great Homer st Back Russell street, Warren
street Back Salisbury street. Carver street Back St. Anne street, Birkt
nhead Back St. Bride street, St. Bride street Back Seel street, Slater
street Back Sir Howard street, Sir Howard st Back Stanley crescent.
North Shore Back Strickland street. Douro street Back Towerlands st.
Holland pi Edge hill Back Vine street, Falkner street Back Whitfield st.
Whitfield st. Tox. pk Back Woolton street, Woolton Baffin street.
West side Queen’s Dock Begot street, Wavertree Hailey street,
Grenville street South Baines place, Breck road, Everton Bakehouse
lane. Stanley street Baker street. West Derby road Baliol road. Bootle
village Ball lane, Claugliton, Cheshire Ball road, Oxton, Cheshire
The text on this page is estimated to be only 23.03%
accurate

STREET DIRECTORY. 'Ball street, Woodchurch road Baltic

buildings, 9, Redcross street Baltimore street, Hardman street
Bamber street, Paddington Banastre street, Vauxhall road Bangor
street, Hook street, Sumner st Bank buildings, 97, Bold street Bank
buildings, 48, Castle street Bank buildings, 41, Lord street Bank
chambers; 3, Cook street Bank chambers, 21, Fenwick street
Bankfield crescent, North Shore Bankfield road, Tue brook Bankfield
street, Dei’by road, Kirkdale Bankhall lane, Sandhills lane Bankhall
street, Derby road, Kirkdale Baptist lane, Gerard street Baptist street,
Baptist lane Bark hill, Lodge lane, Toxteth park Bark hill road,
Aigburth road Barlow lane, Bootle road, Kirkdaie Barlow street,
Baker street, Low hill Barlow street, Bootle road, Kirkdale Barmouth
street, Athol street Burned buildings, Sweeting street Baras street,
Breckfield road South Barrow street, Wliitefield road, Everton
Bartlam street, Jones street, Rupert st Barton lane, Oldhall street
Barton lane, Barton street, Windsor Barton street, Harding street,
Windsor Barton street North, Great Howard st Barwise street,
Salisbury street Basnett street, Church street Basnett street
chambers, 20, Basnett st Bath lane, 9, Bath street Bath street, New
quay Bath street, Waterloo, Crosby Battery street, Regent road
Bayhorse lane, Gildart street Beach bank, Liscard Beach view,
Seacombe Beacon lane, Church street, Everton Beacon street, Athol
street Beaconsfield, Summer seat, Bootle Beau lane, Cazneau street
Beau street, Cazneau street Beaufort terrace, Seacombe Beaumaris
street, Clyde street, Derby rd Bebbington, New Ferry Bebbington
street, Breckfield road North Beckwith buildings, 42, South John st
Beckwith street, Park lane Beckwith street, Camden st. Birkenhead
Bedford place, Derby road, Bootle Bedford place, Mersey lane, Rock
Ferry Bedford road, Chester road. Rock Ferry Bedford street, Hope
street, Birkenhead Bedford street North, Abercromby sq Bedford
street Soutli, Abercromby sq Bedford street, Parliament st. Tox. park
Bedford terrace, Derby road, Rootle Bedford terrace, Low hill Beech
lane, Wavertree Beech street, Kensington Beech terrace. Beech
street Beechwood road, Aigburth road Belgravo street, Erskine street
Belgr.ivc terrace, Lowther street Belgravo terrace, Aurlloy street,
Everton! Bell street, Grafton street, Toxteth park Belle street,
Cazneau street Belle vue, Chester street, Birkenhead Belle vue,
Derby road, Bootle Belle vue, Victoria road, Seacombe Belle vue.
Walton road Belle vue road, Wavertree Belmont, Ox ton road,
Cheshire Belmont road. West Derby road’ Belmoilt grove, Belmont
road, W. Derby Belmont grove, Oxton road, Cheshiie Belvidcro road.
Prince’s park BelvidJfe terrace, Liscard village Ben .Jonson street,
Scotland load Benledi street, Scotland road Beunctt buildings, 13,
Fenwick street Bennett street, Gerard street Benus garden. South
Castle street Benson street, Renshaw street Bent street, Scotland
road Bentinck street, Great Howard street Bentinck street, Conway
sc. Birkenhead Beresford road. Park road Beresford street, Bute
street Berkley street, Upper Parliament street Berner street,
Cleveland st. Birkenhead Berry street, Bold street Berry street.
Merton road, Bootle Berwick street, West Derby road Berwick
terrace, Berwick st. W. Derby rd i Bethesda street, Northumberland
terrace l’.evington ousli. Scotland r a 1 Bevington hill, Bevington
bush Bevington street, Limekiln lane Bewley street. Smith street,
Kirkdale Biekerstaffe street, Soho street Bidston, Cheshire Bidston
view, Oxton road, Cheshire Birch street, Athol street Birchfield,
Islington Birchfield, Edge lane, Stanley Birchfield road, Edge lane,
Stanley Birchfield terrace, Edge lane Birkenhead, Cheshire
Birkenhead buildings, New Chester road Birkenhead park, Conway
street Birkett street, Richmond row Birtles place, Great Nelson street
Bishopsgate street, Wavertree road Bispham street, Marybone
Bittern street, Pomona street Bittoek lane, Garston Bixteth street,
Tithebarn street Black Bull lane, Walton road Blaekbume place, Hope
street Blackburne street, Falkner street Blaekbume terrace,
Blackburne place Blaekbume ter. Grange mount, Claughton Black
Diamond street, Vauxhall road Blackfield street. Rake lane, Kirkdale
Blaekfield terrace. Rake lane, Kirkdale Black Horse lane. Old Swan
Blackpool street, Birkenhead Blackstock street, Vauxhall road
Blackstone street, Great Howard street Blair street, Upper Parliament
street Blake street, Brownlow hill Blanche street, Crown st.
Brownlow hill Blenheim street, Scotland road Blenheim street, Derby
road, Kirkdale Blinkhorn lane. Great Crosby Bloom street. Myrtle
street Blueher street, Edge vale Blueher street, Waterloo, Crosby
Blundell sands, Little Brighton Blundell street, St. James street Blythe
street, Breck road, Everton Boardman place, 190, Scotland road Bold
place, Berry street Bold street. Church street Bolton street, Copperas
hill Bolton street, Bedford st. Tosteth park Bolton street, Mason
street, Edge hill Bond street, Vauxhall road Bootle, North Shore
Bootle lane, Kirkdale Bootle mount, Linacre Bootle road, Walton
Bootle village, through Kirkdale Borough buildings, 10, Water street
Bostock street, Scotland road Bostock street, Derby road, Bootle
Botanic road, Edge lane Botanic view, Smithdown lane Botanic
street, Wavertree road Boundary lane, West Derby road Boundary
place, top London road Boundary street, Scotland road Boundary
terrace, Bute street Bow street, Edgar street Bradbury terrace. Upper
Huskisson st Bramley-Moore Dock, Regent road Brancker street,
Whitfield st. Toxteth pk Brandon st. Hamilton square, Birkenhead
Brandon terrace, Chester st. Birkenhead Brazilian buildings, 8 & 10,
Drury lane Brearley street, Cranbourae street Breck place, Breck
road Breck road, Rupert lane, Everton Breckfield place, Breckfield
road North Breckfield road North, Breck rd. Everton Breckfield road
South, Breek rd. Everton Breckside park, Lower Breck road Breeze
hill, Bootle road, Walton Brcnton street, Park road Bretherton lodge.
6 to 12, North John st Briars The, Edge lane, Stanley Brick street, St.
James street Bridge road, Linacre marsh Bridge street, Chester
street, Birkenhead Bridgewater place, 27, Bridgewater street
Bridgewater street, St. James street Bridport street, Hothain street
Bridson street. Bloom street Bright street, Olive street, Oxford street
Bright street, Everton road Bright street, South hill st. Toxteth park
Brighton place, Seacombe Brighton road, Waterloo Brighton street,
Fletcher st. Toxteth pk Brighton street, Egremont, Olieshirc Brighton
street, Seacombe Brighton ter. Gore st. North, Kirkdale Brighton
terrace. Sandon street Brighton terrace. Reacorftbe Brighton view,
Nethorfield road North Britannia buildings, 20, Fenwick street
Britannia terrace, Haigh street, Everton Broad green, Old Swan
Broad green road, Wavertree Brokers alley, Stanley street Bronte
street, Russell street Bronte terrace, Walton breck road Brook place,
Oak street, Birkenhead Brook street, Oldhall street Brook street,
Upper Parliament street Brook street, Chapel street, Birkenhead
Brook terrace, Mersey st. North, Bootle Brooks alley, Postoftice-place
Broom street, Athol street Brougham road, Seacombe Brougham
street, Sussex st. Toxteth pk Brougham terrace. West Derby road
Brougham terrace, Seacombe Brown street, Rupert street Brownlow
hill, Ranelagh place Brownlow hill terrace, Crown-street Brownlow
street, Pembroke place Browns lane. Great Crosby Brow side,
Everton brow Brace street, Clevedon st. Toxteth park Brunei street,
Breck road, Everton Brunswick buildings, 7, Brunswick st Brunswick
chambers, 17, Hanover st Brunswick Dock, Queen’s Dock Brunswick
Dock basin, Brunswick Dock' Brunswick place, Derby road, Kirkdale
Brunswick mad, Islington Brunswick square Bootle lane, Kirkdale
Brunswick street, Castle street Bruuswiek street, Kirkdale Brunswick
stieet, Chester rd. Rock Ferry Brunswick terrace, North Shore, K’dale
Brunswick terrace, Price st. Birkenhead Brunswick terrace, Waterloo
Buckingham terrace, Windsor street Buckley street, Derby road
Bullen street, Marsh lane, Linacre Burgess street, London road
Burlington street, Scotland road Bumeoose buildings,’ 20, Canning
place, . and 66, South John street Burroughs garden, Bevington hill
Burton street, Luton street, Kirkdale Buiy street, Townsend street,
Great Howard street Bute street. Fox street Butler sti-eet, West
Derby road Buttermere street, Windsor Button street, Whitechapel
Byrom street, Dale street Byrom street, Watson street, BirkenheaoS'
Byrom terrace. Bridge street, Birkenhead CABBAGE hall, Walton
breck Cable street, St. George’s crescent Cable street chambers, 3,
Cable street Calbeek ter. Wellington road, Waisartre© Caledonia
street, Sugnall street Calmet street, Northumberland! terrace' Calvin
street, Vauxhall road Calvin street, Windsor st. Toxteth park
Cambridge street, Arrad street Camden street, London road Camden
street, Price street, Birkenhead Camden terrace, Camden st.
Birkenhead Campbell street, Duke street Camperdown street,
Birkenhead Canada Dock, Battery street Canada street, Derby road,
Kirkdale Canal bank, Bootle village Canal bank, E. side, Canal
Graving Dock Canal bank, W. side, Peckover street Canal basins,
Oldhall street, Leeds street, and Phillips street Caual graving dock,
Canal timber wharfs Canal timber wharfs, top Plumbe street Canning
buildings, 2, South John street Canning chambers, 17, Canning
place, and 59, South Castle street Canning chambers. 4, South John
street Canning Dock, Redcross street Canning place, South Castle
street Canning street, Hope street Canning street, Church street, Eve
Canning street, Woodside Fei-ra Canning terrace, Upper Parlir
Canterbury street, Islingb ; Canton buildings, 15, W Canton street,
Evertc ran Caple street. Park Caracticus streF. V. k ( Caradoek str \ :
Cardwell i..: -1 Cardwe! ki in st Carlisle t street Carlton stm' ree 1
ward street Carlton stn . nd st. Toxteth park Carlton terr, • i ' ;,per
Parliament street Caroline road, jaughton, Cheshire
The text on this page is estimated to be only 25.59%
accurate

STREET directory. 5 Carpenters buildings, Bond street

Carpenters row, Hurst street Carr lane, Club moor Can- lane,
Fazakerley Carrion lane, Wallasey Carruthers street, Vauxhall road
Carson street, Roscommon street Carter street, Upper Stanhope
st.Tox Cartwright place, Byrorn street Carver street, top of Islington
Cases street, Clayton square Castle street. Town hall Castle street,
Kirkdale road Castle street, Netkcrfield road North Castle street,
Windsor Castle view, Derby road, Bootle Catharine street, Falkner
street Catharine street, Church street. Park road Catharine street,
Grange laue,Birkenhead Cathariue terrace, High Seacombo Catharine
ter. Broad green rd. Old Swan Catheart street, Canning st.
Birkenhead Cavendish street, Marybone Cavendish terrace, Prince’s
park Caxton terrace, St. James road Cazneau street. Rose place Cecil
street, Hardwick street Cemeas street, Athol street Cemetery,
Necropolis, Everton Cenietcro, St. James's, Up. Duke street
Cemetery, St. Mary's, Kirkdale Cemetery, Toxteth, Smithdown lane
Cemetery, Rice lane, Walton Cemetery view, Johnson street, Kirkdale
Cemetery view. Upper Parliament street Chadwick mount, North
view, Everton Chadwick street, Great Howard street Chalmers street,
Chatsworth street Chaloner street, Bridgewater street Chandler
street, Reynolds street. Everton Chapel lane, Bedford st. Toxteth
park Chapel lane, Brownlow hill Chapel place, Erskine street Chapel
place, Oliver street, Birkenhead Chapel road, Garston Chapel street,
behind Exchange buildings Chapel street, Higher Tranmero Chapel
street, Price street, Birkenhead Chapel street, Seacombe Chapel
terrace, Derby road, Bootle Chapel walks, Benns garden, S. Castle st
Charles street, Whitechapel Charles street, Cleveland st. Birkenhead
• Church street. Park road Chlir'eh Street,- i-itanhopo street, Windsor
Church street,- Everton village ■ Church street, Holland place, Edge
hill Church street, Chester street, Birkenhead - Church street,
Egremont, Cheshire Church street Soho. Field street, Everton ika
Church street chambers, 57, Church st Church terrace, Tranmere
Oh'wreh terrace, Johnson street, Kirkdale Chu fch view, Irlam lane,
Bootle Cicero street, Patmos street, Everton Circus street. Byrom
street Citron street Palm street Clare street, Islington Clare terrace,
Du>e st. North, Edge Mil Claremont, Higher Tubbing-ton Claremont
grove, < 'iarJmont pi. Kirkdale Claremont place, King st.rcefc,
Kirkdale Claremont ter. Claremont pla’ce, Kirkdale Clarence buildings;
49, North ,Iohn street Clarence Dock, Regent road Clarence grove.
Church street, E ,T rton Clarence street. Mount pleasant Clarence
street, Everton road Clarence street, Smithdown lane Clarence
terrace, Evcrtnn road Clarendon buildings, Tithebarn street
Clarendon buildings, South John street Clarendon rooms, 1 & 11
South John st Clarendon street. Edge hill Clarke street, Chester
street, Tox. park Claugbton, Cheshire Claughton firs, Oxton, Cheshire
Claugbton park, Claughton Claughton range, Claughton park
Claughton road, Conway st. Birkenhead Claughton ter. Claughton rd.
Birkenhead Claughton vale, Claughton road Clay street, Carlton st.
Great Howard st Clayton square, Parker street Clayton street, Byrom
street CTegg street, Prince Edwin street Clement street, Vauxhall
road Cl evedon street. Park road Clerveland buildings, Park lane
Cleveland square, Prices street Cleveland street, Hamilton st.
Birkcnhd Cli fford-street, Islington Clifton crescent, Clifton park,
Birkcnhd Cli/bon park, "Grange lane, Birkenhead Clifton street ,
Prince Edwin street Clivo street, Northumberland street Charlesville,
Devonshire road, Claughton Club moor, Derby breck, West Derby
Charlotte place, Meiley-street Charters street, Vauxiiall road Chatham
buildings, 15, South John street Chatham place, Grinticld street,
Edge hill Chatham street, Bro widow hill Chatsworth street,
Wavertree road Chancer street, Scotland road Cheapside, Dale street
Cherry lane, Bevington-bush road Cherry lane, Walton village
Chesney street, Heath street, Toxteth pk Chesnut grove, Linacre
marsh Chesnut road, Seaforth, Litherland Chesuut street. Mount
pleasant Chester road, Tranmere Chester street, Upper Stanhope
street Chester street, Woodside Ferry Chesterfield street, Upper
Parlian rent st, Childwall, through Wavertree Childwall lane, Childwall
Childwall road, Wavertree Childwall street, Prescot street, Childwall
view nook, Broad g reen road China street, Beresford street Chipping
street, Rodney st.T-axteth park Chisenhale street, Vauxhall i -oad
Chorley court, 145, Dale stre jet Chorley street, Water street Christ
Church road, Claugl iton Christian street, Islington Christian street.
Church s' .Tcet, Everton Christopher street, Walto q road Church
alley, Church str- jet Church hill, Wallasey Church lane. Church str
eet Church lane, St. Micha< J's, Toxteth park Church lane, Seaforth,
Litherland Church lane, Walton Church place, Church street, Everton
Church road, Garsfon Church road. Higher Tranmero Chureh road,
Much ' Woolton Church road, Preser ,t. road, Stanley Chureh road,
Seafoi ,-th Church road, Scacr ,mhe. Cheshire Church road. Wall ;on
village Church road, Wat £rloo Church road, Wa vertree Church
street, L- »rd street Clw.vxl terrace, Berwick st. West Derby rd Clydo
street, Derby road, Kirkdale Coal street. Lime street Coal-yard lane,
Derby road, Bootle Cobdeu street, Everton road Cobden street,
Saudon st. Mount vernon Coburg Dock, south end Queen’s Dock
Coburg street, Spring st. Toxteth park Coburg terrace, West Derly
road Cockspur street, Pownall square Codrington street. Shepherd
street Coleridge street, Kensington College lane, Paradise street
College street East, Greenside College street North, Shaw street
College street South, Shaw street Collingwood Dock, Regent road
Collingwood street, Scotland road Collins street, Park road Colonial
buildings, 36, Dale street Colquitt streot, Bold street Colquitt terrace.
Back Colquitt stree Coltman street, Wightman street , Columbia
buildings, 30, Brunswick street; Columbia road, Oxton, Cheshire
Combermerc street, Park road Commerce buildings, 12, Tithebarn
street Commerce court, 11, Lord street Commerce street, Chester st.
Birkenhead Commercial buildings, 17, Water street Commercial bags.
Chester st. Birkenhead Commercial buildings, Derby rd. Bootle
Commercial court, 17, Water street Commercial Bank buildings, 4,
Cook st Commutation row, Islington I Compton buildings. 1G,
Tarletpn street Compton street, White-field /d. Everton ' Comus
street, Richmond row Concert street, Bold street Conway street,
Great Homer street Conway street, Hamilton st. Birkenhead Cook
street, Castle street Cookson street. Upper Pitt street Cooper street,
Stanhope street Coopers row, East end Canning place Copperas hill,
Ranelagh street Cordon street. Park road Corfs buildings, 9,
Preesons row Corlett street, Falkner street, Windsor Com Exchange
bdgs. Brunswick street Cornwall street, Netherlicld road South
Cornwallis street, Duke street Coronation street. Field street, Everton
Corporation road. Bridge st. Birkenhead Cottage street , Trinity
street, Birkenhead Cottenhani street, Kensington Cotter st. Up.
Harrington st. Tox. park Covent garden. Water street Cow lane.
Primrose hill. Fontenoy street Cow lane, Wavertree village
Cranbourne street, Paddington Cranmer street, Vauxhall road Craven
road, Deys lane, West Derby Craven street, London road Craven
terrace, Upper Parliament street Creer street, Collingwood street
Crescent chambers North, 3, Lord street Crescent chambers South,
6, Lord street Crescent road, Seaforth Crcssington park, Aigburth
Cresswell street, Everton road Cresswell terrace, Cresswell st.
Everton Croft street, Epworth street. Low hill Croft street, Up.
Parliament st. Windsor Crompton l ine, Wavertree Crompton street,
Athol street Cromwell street, Oliver street, Birkeuhd Cromwell ter.
Berwick st. West Derby rd Crooked lane, North side Canning placo
Cropper street, Lawton street fresbie street, St. James street Crosby,
through Bootle Crosby green, West Derby village Crosby road,
Waterloo Croslieid road, Edge lane Cross street, Hopwood street
Cross street, Market cross, Birkenhead Cross street, Derby road,
Bootlo Cross street, Queen buildings, Tranmere Cross Eldon street,
Eldon street Crosshall stroet, Dale street Crossley buildings, 18a,
South Castle st Croston court, Cunliflb street Croston street, Scotland
road Croston street. Parliament street Crow street, Stanhope st.
Toxteth park Crown chambers, 18, Redeross street Crown place,
Crown street Crown square, Crown street Crown street, Pembroke
place Crown terrace, Crown street Croxteth Line, West Derby village
Croxteth road, Prince's park Cramp street, Greenland street Cuckoo
bine, Gateacre Cuerden street, Byrom street Cumberland street, Dale
street Cumberland terrace, Up. Parliament st Gumming street, Park
road Cummings street, Cornwallis street Cunliffe street, Tithebarn
street Currie street, Bevington hill Custom house arcade, Canning
place » Custom house lane, E. end Canning place Cymry street, Pool
street, Birkenhead Cypress street, Bedford street South DACRE hill,
Rock Ferry Daere place, Argyle street, Birkenhead Dale street, Town
hall Dale street, Whetstone lane, Birkenhead Dalrymple street,
Scotland r'oad Dalton street. West Derby street Daly street. Oriel
street Dance street, Rupert street Dansie street, St. Andrew street
Dantzic street. South end Queen's Dock Darby road, Aigburth
Darlington street, Egremont Darwen street, Athol street Date street,
Almond street Daulby street, London road Davies street, Dale street
Davies street, Oliver street, Birkenhead Dawber street, Reynolds
street, Everton Dawson place, Hunter street Dawson street,
Whitechapel De Riddcr ten-ace, Upper Parliament st Deacon street,
Everton road Dean street, Waterloo Deane street, Elliot street Deane
street, Kensington Dec street. West Derby road Dell 'ihe. Rook Ferry,
Cheshire Demean street, Seacombe Denbigh street, Great Howard
street Deubigb street, Jackson st. Birkenhead Denbigh terrace,
Crown street Denison street, Great Howard street Denman street,
Kensington street Denton street, Park road Derby buildings, 24,
Fenwick street Derby park, Roek Ferry
The text on this page is estimated to be only 23.00%
accurate

STREET DIRECTORY, 6 / Derby park ter. Derby park Rock

Ferry Derby place, Edge lane, Stanley Derby road, Bootle Derby
road, Kirkdale Derby road. Old Swan Derby square, Castle street
Derby street, Whitechapel Derby street, Wavertree road, Edge hill
Derby terrace, Linacre marsh Derby terrace. Summer seat, Bootle
Derby terrace, West Derby road Derwent road, Green lane, West
Derby Derwent terrace Derwent rd. 'West Derby Devon street,
Stafford street Devonport street, Upper Park street Devonshire place,
Netherfield road North Devonshire pi. Devonshire rd, Claughton
Devonshire road, Prince's park Devonshire road, Claughton, Cheshire
Devonshire street, Sussex st. Toxteth pk Devonshire terrace,
Devonshire road, Prince's park Devonshire terrace, St. Domingo road
Dexter street, St. James place Deys lane, Town row. West Derby
Dickinson street. Park lane Dickson street, Great H.ojvard street
Dickson terrace, Soho street Dickston street, Smithtield street Digby
street. Park road Dingiobank, Park road Dingle lull. Park road Dingle
lane, Castle street, Kirlcdalc I linglo lane. Park road Dingle mount,
South Dill road Dingle terrace. South lull road Dingle view, Dingle
lane, Toxteth park I Dinorbcn street, Upper Parliament street; Disle.v
street, Gloucester street Division street, West Derby road Dixon
street, Heath street, Toxteth park Dock road, Garston I (oiling street,
Heath street, Toxteth park Doncaster street, Scotland road Doran
lane, Lord street Doran place, Doran lane. Lord street Douglas
street, Parliament place Douglas street, Birkenhead Douglas street,
Bootle lane, Kirkdale Douro place, Edge lane, Stanley Douro street,
Bute street Dover street, Brownlow street Dover street. Heath street,
Toxteth park' Dover street, Portland place, Everton Downe street,
Richmond row Downehire terrace, Upper Parliament st | Drayton
street, Coilingyvood street Drinkwater gardens, Birkett street Druid
court, i>. Dale street Drury buildings. Water st. & Drury lane Drury
lane, Water street Drydcn rom 1, Edge lane, Stanley Drydeu stre et,
Scotland ro ad Dubliu stria ;t, Great Howard .street Duckinticld
street, Brownlow hill Duckworth street, Fontcui )y street Duckworth
street, Brunsw ick road Dmllow lain e, Wavertree Duke street i
Hanover strci Duke street , Great Homer street Duke street . Brook
street. Birkenhead 1 dike street , Wavertree ro: id. Edge hill Duke
street , HI. Paul's re. i d, Tranmere Duke st. N irtli, Wavcrtvci i rd.
Edge hill * Hike street lane, Duke str cet fluke’s Docl ,, Wapping
Duke’s plaei o, Duke's Dock Duncan stre :et, St. James s treet
Diuican stre :et, Hamilton s q. Birkenhead Dunilas stre et, Walton
roa d, Kirkdale Dundee stre iot, Great How ard street Dutton strci et,
Canal basin, , Oldhall street Dwerrylioir sc laue, Norris green
Dwerryhoir so street, Purli: iment street EAGLE-cb.i imbers, 10,
Fenwick street Eagle quay. Sefton street. Toxteth park Eagle terra*
re. Upper Hill : st. Toxteth pk Earl street, Great Homer s treet Earle
street , Edmund strci Earls ton m ul, Discard East street, St. Paul’s
squi ire Waterloo Eastbourne street, Shaw si troot, Everton Eaton
road, Glaughton Eaton road, , Drill lime. We >t Derby t, Crown
street Edge hill. Browulo raigc lane, .uouut veruou Edge mount.
Paddington Edge vale, Smitlidown lane Edinburgh street, Great
Homer street Edmund street, Oldhall street Edmund street. Wood
street, Toxteth pk Edward street, Conway st. Birkenhead Edward
street, Rupert street Edward street, Everton road Edwards street, St.
Domingo road Edwards street, Wolfe street, Toxteth pk Egerton
Dock, Canning st. Birkenhead Egerton Dock, Sefton st. Toxteth park
Egerton place. Discard Egerton street, Sandon street Egerton street,
Park road Egerton street, Grange st. Birkenhead Egerton villas, Old
Chester road Egremont, Cheshire Egremont road, Lisearel Egypt
street, Arrad street Eldon chambers, 20, South John street Eldon
grove, South Tranmer-e Eldon place, Vauxhall road' Eldon lane. Old
Chester road, Tranmere Eldon place, Eldon street, Birkenhead Eldon
street, Vauxhall road Eldon street, Price street, Birkenhead Eleanor
street, Mersey street North Elgin street, Seacombe lane. Belle street
Elizabeth street, Pembroke place Elizabeth street, Bootle lane,
Kirkdale Elizabeth street, Whetstone lane, Birklid Elizabeth street,
Thomas st. Birkenhead Ellenborough street, Scotland road Ellesmere
street, Mount Vernon street Ellesmere terrace, Spencer street,
Everton Elliot street, Clayton square Ellison street. Great Horner
street Elm grove, Sraithdown lane Elm grove, Christopher st. Walton
road Elm lane, Higher Tranmere Elm road, Seaforth Elnr road. West
Derby street Elm street, Elm road. West Derby street Elm terrace.
Beech street Fairfield Elnr vale, Fairfield, West Derby Elms, The, Peel
street, Toxteth pEi-k Elmswood road Aigburth vale Elton street,
South street, Toxteth park Enrbledon street, Upper Parliament st
Emma Ann street, Thornton street Errlrut lane. Great Crosby Enfield
terrace, Claughton, Cheshire Eunerdale street. Limekiln lane *
Epsom street. Latimer street Epworth street. Preseot street Ermine
street, Mere lane, Everton Errington street, Victoria road, Kirkdale
Erskine street, top of Islington Esklrolnre street, Derby road, Kirkdale
Esplanade, Tire, Waterloo, Crosby Esplanade, The, Rock Ferry Essex
street, Northumberland street Eustace street, Paddington Euston
grove, Grange mount, Claughton Evans street, Tatlock street Everton
brow, Everton crescent Everton crescent, Richmond row Everton
road, Brunswick road Everton terrace. Everton brow Everton valley,
Kirkdale road Everton view, Derby road, Bootle Everton village.
Everton brow Every street. West Derby road Ewart street, Lord
street. Edge hill liiy bank street, Northumberland terrace Exchange
alley. Exchange street West Exchange alley North, 5, Oldhall street,
and 1(1. Chapel street Exchanpe buildings, Town hall Exchange
chambers, Tithebarn street Exchange court. 28, Exchange st. East
Exchange place. 32, Exchange st. East Exchange street, South
street, Tox. park Exchange street East, D;de street Exchange street
West, Town hall Exeter street, Morningtou st. Toxteth pk Kxmouth
street, Comvay st. Birkenhead Exmouth street, Everton road
FAIRCLOUTII lane, top Pembroke pi Kairclough lane, O.xton,
Cheshire Fairclough street, Ranelagh street I Fairfield, Kensington,
Proscot road I Fairfield crescent, Prospect vale Fairfield street,
Fairfield i Fairfield terrace. Edge lane Fairfield terrace, Well lane,
Tranmere I Fairhurst street. Chcapsidc Fail-view. Fail-view place. Park
road Kairview place, Park road l-’airi i.-.w road, Oxt m Falkland
street, Loudop road Falkacr ere . at, Derby road, Bootle Valkner
square, Sandon street * — Falkner street, Hope street Falkner ten-
ace, Derby road, Bootle Falkner terrace. Upper Parliament street
Fazakerley, through Walton Fazakerley street, Oldhall street Feather
street, Richmond row Fenwick buildings, 12, Fenwick street Fenwick
chambers, 8, Fenwick street Fenwick court, 8, Fenwick street
Fenwick street. Water street Fernleigh, Poplar road, Oxton Ferry
road, New Brighton Ferry road, Seacombe Field lane, Litherlaud Field
street, Everton crescent Field street, Wood street, Birkenhead Field
view, Bootle lane, Kirkdale Finch lane, Knotty Ash Fince place,
Falkland street Finch street, Norton street Finney lane, Thomas
street Fir grove, Blackhorse lane. West Derby Fisher street, Grafton
street, Toxteth pk Fleet street, Hanover street Fletcher gardens,
Birkett street Fletcher grove, Edge lane, Stanley Fletcher street,
Upper Stanhope street Flint street. Brick street Florist street, Oxford
street Folly lane, Wallasey Fontenoy street, Dale street Forbes st.
Chatsworth st. Wavertree road Ford, through Bootle Ford street,
Vauxhall road Formbv street, Great Howard street Forrest street.
Park lane Fort terrace, Derby road, Bootle Fort terrace. New Brighton
Foundry lane, Aigburth street, Windsor Fox street, Richmond row
Franceys street, Clarence street Francis street, Wellington rd. Toxteth
pk Frank street, Bedford street, Toxteth pk Franklin place, Whitefield
road, Everton Franklin terrace, Whitefield rd. Everton Fraser street,
London road Frederick street. South side Canning pi Freehold street,
Fairfield Freeman street, Bridge st. Birkenhead Freemasons row,
Vauxhall road Fulford street, Kirkdale road Fulton street. Great
Howard street Fulwood park, Aigburth road Fylde street, Ess«k
street, Toxteth park GADSBY street, Rokeby street, Everton Gal ton
street, Great Howard street Gambier terrace, Hope street Gambier
terrace, Irlam lane, Bootle Garden lane, Prince Edwin lane Garden
street, Smithdown lane Gardeners row, Marybone Gardner road, Tue
brook, West Derby Garston, through Aigburth Garstou lane, Allerton
Garston Old road, Garstou Gascoyde street, Vauxhall road Gascoyne
street, Old Swan Gateacre, through Wavertree Gay street, Scotland
road George street, Oldhall street George street, Mount Vernon
street George street, Park road George street, Sandford st.
Birkenhead George’s Dock, bottom of Water street George’s Dock
basin. Chapel street George’s Dock gates North, Water street
George’s Dock passage, bottom James st George's road. West Derby
road Gerald street, Erskine street Gerard street, Byrom street
German terrace, Price street, Birkenhead Gertrude street, Duncan st.
Birkenhead Gibbons lane, Queen street Gibraltar row, Great Howard
street Gibraltar street. Great Howard street Gibson street, Carter
street, Toxteth pk Gilbert street, York street Gildart street, London
road Gildarts gardens, Limekiln lane Gilead street, Kensington
Gillbrook, Corporation road, Birkenhead Gillmoss lane, Croxtoth-ball
lane Gill street, Pembroke place Gill street Market, Gill street (
iladstone street. Freemasons row Glasgow street. Paisley street <
fiasshouse lane, Mill lane, Old Swan ( Ilea vc street, Everton road
Clegg street, Great Howard street Glcnvale street, Greek road,
Evertou Gloucester place, Dow hill Gloucester place, Netherfield road
North I Gloucester street, Lime street
The text on this page is estimated to be only 27.68%
accurate

STREET DIRECTORY. 7 Gloucester street. Mason street,

Edge hill Glover street, Sefton street, Toxtctli pk Gomer street, Soho
street Gordon street, Great Homer street Gore street. Stanhope
street Gore street North, Scotland road Goree piazzas. East side
George’s Dock Gorsey lane. Ford Goulden street, Harbord street,
Edge hill Gower street, Salthouse Dock Gradwell street, Hanover
street Grafton street. Parliament street Grange lane. Grange street,
Birkenhead Grange lane. Little Woolton Grange lane, Wellington
road, Wavcrtreej Grange mount, Claughton, Cheshire Grange street,
Chester street, Birkenhead Grange terrace, Wavertree village Grant
read. Pilch lane. Knotty Ash Grassendale park, Aigburth Grassendale
road, Aigburth Graving Docks, Nos. 2 & 3, Nova scotia Graving
Docks, Nos. 4 & 5, West side Queen’s Dock Graving Docks,
(Brunswick) Sefton st Graving Docks, (Clarence) Regent road
Graving Docks, (Saudon) Regent road Grayson street, Hurst street
Great Charlotte street, Whitechapel Great Crosby, through Bootle
Great Crosshall street, Tithebam street Great George place. Great
George street Great George road, Waterloo. Crosby Great George
square. Upper Pitt street Great George street, Duke street Great
Homer street, Fox street Great Howard street, Oldliall street Great
Mersey street, Kirkdale road Great Nelson street, Scotland road
(treat Newton street, Pembroke place Great Orford street, Mount
pleasant Great Oxford street, Scotland road Great Richmond street.
Rose hill Grecian terrace, Northumberland terrace Greek street,
London road Greenback, through Smithdown lane Greenheys,
Riversdale road, Aigburth Greenheys road, Prince’s park Green lane,
Pleasant street Green laDe, Seaforth Green-lane, Tue brook. West
Derby Green lane, Egremont Green lane, Old Chester road, Tranmere
; Green lane, Wallasey, Cheshire Green lane, Wavertree Green side,
Brunswick road Green street, Crown st, Brownlow hill Green street,
Vauxhall road Greenland street, St. James street Greenock street.
Paisley street Green way ter. Walker st.HigherTranmere Greenwich
road, Melling road, Walton Greenwood street, Thomson st. Everton
Oreetham street. Park lane Gregorj' place, Gerard street Grcgson
street, top Brunswick road Gregson street. Park road Grenville street
North, Scotland road Grenville street South, Kent street Grey horse,
Knotty Ash Grey street, Windsor street, Toxteth pk Griffiths street.
Hardy street Grinfield street, Oxford street Grintield terrace, Grinfield
street Grosvenor road, Claughton, Cheshire Grosvenor square,
Victoria rd. Seacombe Grosvenor street. Rose place Grosvenor
street, Chester rd. Rock Ferry Grove mount. Holt hill, Tranmere
Grove park. Lodge lane Grove place, Bootle lane, Kirkdale Grove
road, Fairfield, West Derby Grove road, Old Chester rd. Rock Ferry
Grove road. Wallasey, Cheshire Grove street, Aigburth Grove street,
Crown street Grove street, Wavertree village Grundy street, Victoria
road, Kirkdale ' Guilford street, Edward st. Everton rd I UACKINS
hey. Dale street Had assail grove, Lark lane, Toxteth pk Hadwen
buildings, Tithebam street Haigh street, Everton brow Hale street.
Dale street Halewood, through Gatoacrc Halewood lane. Little
Woolton Haliburton street, Park road Halkin street, Hampton st.
Birkenhead Hall lane, Mount veraon Hall lane, Cam lane. West Derby
Hall street. Much Woolton Hallstead road, Poulton, Cheshire
Hamilton buildings, Hamilton st. Birkhdi Hamilton chambers,
Hamilton st. Birkhd Hamilton lane, Cleveland street, Birknhd [
Hamilton square, Hamilton st. Birknhd | Hamilton street, Bridge
street, Birknhd ! Hamlet The, Wellesley tor. Prince’s park Hampton
street, Windsor st. Toxteth pk Hampton street, Oliver st. Birkenhead
Hankin street, Sumner street Hanley street, Lime street Hanover
chambers, 21, Hanover street Hanover street. Canning place
Hanover street. Slater street, Toxteth pk Hapsford lane, Linacre lane,
Litlierland Harbord street, Wavertree road Harding street, Falkncr
street, Windsor Hardman street, Rodney street Hardwick square,
Hardwick street Hardwick street, Prescot street Hardwick ter. Berwick
st. West Derby rd Hardy street. Great George street Hare place,
Scotland place Harford lane, Harford street Harford street, Mount
pleasant Harker street, Springfield Harper street, Mill street, Toxteth
part Harper street, Prescot street Harper terrace, Upper Parliament
street Harriet street. Mill road, Everton Harrington chambers, 24 &
26, North John street Harrington Dock, Sefton street Harrington
street, Castle street Harrington street. Parliament street Harrison
street, Marybone Hart street, London road Hartley street, Seacombe
Hatfield street, Paddington Hatton garden. Dale street * Havelock
street, Netlierfield road North Havelock street, Seacombe Havelock
ter. Berwick st. West Derby rd Hawke street, Brownlow hill
Hawkstone street, South st. Toxteth pk Haworth street, Reynolds
street, Everton Haymans green. West Derby village Haymarket,
Great Nelson street Hayton street, Crown street Head street, Dexter
street, Toxteth park Heath street, Falkner street Heath street, Hill
street, Toxteth park Heath terrace, Woodchurch road Heather street,
Tetlow street Heathfitld road, Wavertree Heathfiehl road, Oxton,
Cheshire Heathficld street, Renshaw street Heaton place, Breck road,
Everton Hedley street, Athol street Helena street, Harbord st.
Wavertree rd Hemer terrace, Linacre marsh Hcmingford street,
Conway st. Birkenhd Hemingford terrace, Conway st. Birkenhd
Henderson street. Hill street, Toxtctli pk Henry street, Campbell
street Henry street, Roscommon street Henry street, Market street,
Birkenhead Henry Edward street, Standish street Herculaneum Dock,
Sefton street Hicks road, Sandy lane, Seaforth High park street. Park
road High park terrace, Park road Higli street, Town hall High street,
Netlierfield road N. Everton High street, Wavertree road, Edge hill
High street, Much Woolton High street, Wavertree village Higham
street, Roscommon street Highfield park. Rock Perry Highfield road,
Sandstone roail.W. Derby Highfield street, Tithebam street Highfield
terrace, Derby lane, Old Swan Highfield view, Highfield road, W.
Derby High Seacombe, Cheshire Higher Bebbington. Cheshire Higher
Tranmere, Cheshire Hill side, Wallasey, Cheshire Hill street. Copperas
hill Hill street, Priory street, Birkenhead Hill street, Roscommon
street Hill street, St. James place Hinderton lane. Tranmere, Cheshire
Hockenhall alley, Dale street Hodson place, Everton village Hodson
street. Great Crosshall street Holborn street. Low hill Holden street.
Upper Parliament street Holford street, Brunswick road Holland
street. Present road, Fairfield Holland street, Thornton place,
Tox.park Holland terrace, Brunswick road I lolland terrace, 1 Hike st.
North, Edge hill Holliwcll street, West Derby road Hollybank road,
Clifton park, Birkenhead Holly road, Beech street Holly street,
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