Heritage Characterisation and Preservation Strategies for the Original Shantung Christian University Union Medical College (Jinan)—A Case of Modern Mission Hospital Heritage in China

Abstract

At the turn of the 20th century, Christian and Catholic churches in Western nations established numerous mission hospitals in non-European regions. In China, mission hospitals represent a significant category of modern architectural heritage, symbolising advancements in healthcare and medical education while also serving as historical artifacts of early cultural interactions between China and the West. With ongoing developments in medical technology, these mission hospital structures no longer meet contemporary healthcare demands; many have been repurposed or temporarily abandoned. Preserving and effectively repurposing mission hospital heritage has thus emerged as a critical issue. In the present study, the Shantung Christian University Union Medical College was examined as a case study in addressing this challenge. The site retains the original Outpatient Building, Inpatient Building, Medical Teaching Building, and other architectural heritage and has preserved the original mixed Chinese and Western architectural styles. A combination of historical research, field investigation, and historic layering was adopted in the present study, drawing primarily on data from historical maps, satellite images from different periods, aerial photography from drones, architectural drawings, and other relevant historical data. Through case studies, methods for characterising and identifying the landscape and architectural heritage of mission hospitals were explored. Principles for the preservation and regeneration of the heritage of church hospitals were also proposed, with a view to providing a reference for the study and preservation of this type of heritage.

1. Introduction

Mission hospitals refer to medical institutions established by Western Christian and Catholic churches during the late 19th and early 20th centuries. In numerous regions, these hospitals formed the foundation of extensive medical networks that introduced Western medicine to local communities [1]. For instance, Protestant and Catholic missions were instrumental in advancing Western medical practices and public health across much of Africa, often decades before colonial governments offered similar healthcare services. Medical missions significantly improved local healthcare conditions by enhancing hygiene practices and reducing mortality rates [2]. Beyond their health impact, the establishment of mission hospitals bolstered the scientific reputation of these religious organisations and afforded them political influence [3]. Presently, church-affiliated hospitals and healthcare programs continue to deliver between 25 and 50 percent of available healthcare services in many African nations [4]. In Uganda, for example, numerous rural areas rely solely on church-run health facilities for medical services [5].

In the early 20th century, mission hospitals in China expanded rapidly, reaching 254 establishments by 1937 [6]. Large mission hospitals of this era frequently integrated medical practice with medical education, operating as medical colleges. Notable examples include Peiping Union Medical College, Shantung Christian University Union Medical College, the College of Medicine of West China Union University, and Hunan-Yale Hospital, each distinguished by their early establishment and considerable scale [7,8]. These institutions typically encompassed outpatient and inpatient buildings, educational facilities for students, faculty offices, and dormitories for both medical staff and students. While many of these structures have been demolished over the past century, Shantung Christian University Union Medical College preserves a significant portion of this architectural legacy. The survey for this study was conducted from the end of 2022 to the end of 2023. This paper utilises a case study approach to examine methods for identifying and characterising the built heritage and landscape of mission hospitals in modern China, aiming to provide a framework for the preservation and revitalisation of such heritage.

1.1. Research Review

Modern hospitals began to emerge in Europe as a result of the Enlightenment era in the 18th century. By the second half of the 19th century, along with the development of medical science and surgery, hospitals and the medical profession became more specialised [9]. At the same time, the training of doctors and nurses became more standardised. Florence Nightingale was a pioneer of the modern nursing profession during the Crimean War, emphasising delegated patient care and systematic hospital management [10]. This transformation in hospital care in Europe subsequently influenced developments in the United States, where, by the late 19th and early 20th centuries, hospitals evolved from “the last charitable resorts for the sick poor” to “the premier locations of cutting-edge medical treatment for all classes” [11].

With advancements in medical science, hospital architecture also underwent significant modernisation. In the latter half of the 19th century, British hospitals predominantly adopted the pavilion style, featuring courtyard layouts that enhanced ventilation within wards and minimised cross-infection risks [12]. However, with the discovery of tuberculosis and its transmission pathways, the pavilion-style architecture gradually fell out of favour. Subsequent hospital designs prioritised healthy environments and introduced more structured, scientific healthcare management. Nightingale-style hospital wards became emblematic of this period, reflecting a shift towards more sanitary, functionally organised hospital spaces [13].

Research on modern Chinese church hospitals has shown a clear trend toward multidisciplinary investigation, integrating perspectives from fields such as history, medical sociology, and architecture. In historiography, early research was predominantly conducted by Western missionaries in China, who documented the trajectory of Western Christian medical missions [14,15], the development of medical missions [16,17], and studies of specific regions and significant cases [18,19]. Research by mainland Chinese scholars provides a broader view, addressing the motivations and evolution of medical missions in modern China [20], the rise and development of healthcare in the late 19th and early 20th centuries [21], and the overall progression of mission hospitals across various regions [22]. Studies have also focused on the geographical distribution of church hospitals, particularly in cities along the Grand Canal [23], and the history of church hospitals within specific areas [24,25]. Case studies of notable mission hospitals, such as Huamei Hospital in Linqing, have further enriched this body of research [26].

In medical sociology, research has explored the influence of Western church hospitals on Chinese societal development. Early studies often framed the medical profession primarily as a vehicle for religious propagation [27]. However, since the 1980s, scholars have increasingly acknowledged the constructive role of mission hospitals in advancing the modernisation of healthcare in China [28], contributing to social charity and relief efforts [29], and promoting societal improvements [30]. Some scholars argue that mission hospitals demonstrated a high degree of adaptability to Chinese society due to their scientific and institutional strengths, facilitating their integration and positive impact within local communities [31]. In the early years of Western medicine in China, public perception evolved from fear and scepticism to trust and respect. The effectiveness of Western medical practices played a crucial role in earning the confidence of the Chinese public [32]. Research on this topic has increasingly bridged multiple disciplines—including sociology, medicine, history, and religious studies—resulting in a new interdisciplinary paradigm for studying church hospitals [33].

In the field of architectural studies, previous research has involved studies in the areas of architectural history of mission hospitals, architectural styles and forms, and heritage conservation. The research field of architectural history focuses on the localisation process of Western hospitals in China and the cultural exchange between Chinese and Western architecture [34,35]. It also provides a historical examination of the functions and spaces of hospital architecture [36]. The localisation efforts of notable ecclesiastical architects, such as Henry K. Murphy, have also become significant subjects of research [37,38,39]. Additionally, regional studies, including those focused on mission hospitals in Guangzhou and Wuhan [40,41], as well as case studies on prominent institutions such as Union Hospital [42,43], Hsiang-ya Hospital [44,45], and Cheeloo Hospital [46], offer valuable insights. These studies primarily examine the architectural style and design of mission hospitals, shedding light on early cultural exchanges between Chinese and Western architectural traditions. In addition, these studies deal with the common building characteristics of the mission architectural heritage, exploring the characteristics of the decorative arts mainly from the perspective of cultural exchange between China and the West. Research on the heritage of surviving mission hospitals largely centres on assessments of current architectural conditions [47], preservation strategies [48], and restoration techniques [49].

Although established studies have provided support for the perception of the historical and cultural value of the architectural heritage of mission hospitals, there is a lack of detailed research on the preservation and regeneration of this building type. Notably, the architectural heritage of Chinese mission hospitals has three distinctive features:

(1)

Along with the continuous development of medical technology, mission hospital buildings can no longer adapt to contemporary medical needs. Many original mission hospital buildings have been converted to other functional uses, such as offices and administration.

(2)

A representative mission hospital is often a complex or historic district composed of several buildings, and the historical environment of the architectural heritage should be considered as a whole in its preservation and utilisation.

(3)

The architecture of church hospitals reflects the characteristics of cultural exchanges between the East and the West, reflecting cross-cultural integration in architectural style and decorative arts.

The preservation and adaptive reuse of modern hospital buildings have become common topics in international discourse. Initially designed as facilities focused on inpatient care, these buildings now face challenges due to evolving social needs and demands [50]. Advances in genetics, biotechnology, and information technology have expanded hospital functions to include training, research, and various ancillary services [51]. Consequently, older hospitals must adapt to changing standards in healthcare regulation and ongoing medical advancements [52]. In response, many historic hospital structures have been repurposed or abandoned. For instance, several Italian hospitals have been converted into museums, hotels, offices, and other uses [53,54,55], aligning with the sustainability principles of urban heritage by transforming these structures into resources with contemporary relevance [56]. Some scholars argue that modern hospitals have, in effect, become historical artifacts and advocate for integrating evolving perceptions of health and illness into the cultural valuation of these hospitals [57].

In 2011, the United Nations Educational, Scientific and Cultural Organization (UNESCO) issued the Recommendation on the Historic Urban Landscape. This document builds on a series of standard-setting charters and guidelines for conserving historic towns and cities, beginning with the Venice Charter, and incorporates interdisciplinary research findings on urban natural and cultural landscapes from archaeology, geography, architecture, and urban planning [58]. Historic Urban Landscape (HUL) refers to “urban areas where cultural and natural values and attributes have been historically layered”. Historical layers are a defining characteristic of the Historic Urban Landscape [59]. Over time, as cities evolve, layers from different historical periods accumulate, shaping the contemporary historic cityscape [60]. Analysing the historic urban landscape offers insights into the unique qualities that contribute to an area’s sense of place, supporting both a favourable living environment and the sustainable development of historic urban zones [61,62]. This integrated approach, which considers the built environment alongside architectural heritage, provides a comprehensive framework for preserving and revitalising mission hospital heritages.

1.2. Research Intention

Since the onset of the 21st century, Chinese hospitals have increasingly emphasised the integrated development of medical care, education, and research, adopting a medical education model that combines research, learning, and practice. This shift has opened new avenues for the preservation and advancement of mission hospital heritage. In line with cultural sustainability—which involves the protection, maintenance, and preservation of all forms of culture for equitable access by current and future generations—mission hospital heritage serves as a valuable cultural resource [63]. It stands as both a historical testament to the modernisation of healthcare and medical education and as tangible evidence of early cultural exchanges between China and the West. Through case studies, the aim of the present study was to develop an integrated research approach for the landscape and architectural heritage of mission hospitals, proposing principles for their preservation and adaptive reuse. Furthermore, this study examines the environmental, spatial, and architectural characteristics of the mission hospital heritage, and the perspectives and methods developed in the present study can also be applied to the generalisation of this type of architectural heritage.

2. Materials and Methodology

2.1. History of Mission Hospitals in China

The development of modern Chinese mission hospitals reflects the history of the introduction of Western medicine into China, its intermingling with traditional Chinese medicine, and its eventual promotion of modern Chinese medicine. The development of mission hospitals in China roughly covers three periods.

The first period was from the early 19th century to the end of the 19th century, when Western missionaries began to set up hospitals in China, mainly in Shanghai, Guangzhou, Hong Kong, and other coastal cities [29,32]. Early hospitals mainly relied on existing buildings, and they were small in scale, poorly equipped, and could only provide simple medical services [21].

The second period was from the beginning of the 20th century to the founding of the People’s Republic of China in 1949. Following the Boxer Rebellion in 1900, Christian churches in China began to consolidate, leading to the expansion in both the number and scale of mission hospitals, with their reach extending progressively into mainland China [27,64,65]. These mission hospitals introduced advanced Western medical equipment and technology, and they established medical and nursing schools, thus laying a foundational framework for the development of modern medicine in China [66,67].

The third period spans from 1949 to the present. After the founding of the People’s Republic of China, mission hospitals were nationalised and are still operating as hospitals. However, after the Reform and Opening Up policy in 1978 and the subsequent development of the modern medical service system, the original mission hospital buildings increasingly struggled to meet the spatial demands of contemporary healthcare [68]. Consequently, many mission hospital structures were either demolished and rebuilt or repurposed, ceasing to function as medical facilities [69].

Over more than a century of mission hospital development, while their primary objective was the propagation of Western religion, these institutions played a significant role in disseminating Western medical knowledge, training healthcare professionals, and advancing medical technology. Together, these contributions laid the groundwork for China’s modern medical system. Additionally, modern Chinese church hospitals stand as historical witnesses to cultural exchanges between the East and West and symbolise broader societal progress.

2.2. Case Selection

Shantung Christian University Union Medical College, Peiping Union Medical College, Hunan-Yale Hospital, and the College of Medicine of West China Union University are among the most renowned mission medical colleges and hospitals in modern China (

Table 1. Basic information on the four major mission hospitals (based on [6,70,72]).

Current Name	Date of Establishment	Location	Original Names	Original Sponsoring Organisations
Qilu Hospital of Shandong University (QLH)	1904	Jinan, Shandong	Shantung Christian University Union Medical College, Cheeloo College of Medicine	Presbyterian Church of England, Presbyterian Church in the U.S.A. (North)
Peking Union Medical College Hospital	1906	Beijing	Peiping Union Medical College, North China Union Medical College, Union Medical College at Peking	American Board of Commissioners for Foreign Missions, London Missionary Society, American Presbyterian Mission (North), etc. China Medical Board of the Rockefeller Foundation assumed full support in 1916.
Xiangya Hospital of Central South University	1908	Changsha, Hunan	Hunan-Yale Hospital, Yale-in-China Hospital, Hsiang-ya Hospital	Yale-in-China Association
West China Hospital of Sichuan University	1914	Chengdu, Sichuan	College of Medicine of West China Union University	Board of Governors representing Mission Boards of British, American, and Canadian Missions

) [70,71,72]. These institutions share similarities in architectural style and development, incorporating large, classical Chinese-style roofs that contribute to a distinctive Chinese aesthetic in mission hospital design. Since 1949, to accommodate population growth and the increasing demands of modern healthcare, these four hospitals have undergone numerous modifications and expansions, leading to significant alterations in their original spatial configurations [68,73].

Based on satellite maps and historical surveys (Figure 1), it is evident that the West China Hospital of Sichuan University was upgraded from its 1950s-era compound, allowing the original hospital complex to remain largely intact. In contrast, the other three hospitals—Peking Union Medical College Hospital, Xiangya Hospital of Central South University, and Qilu Hospital of Shandong University (QLH)—have been reconstructed and expanded on their original sites, featuring a typical juxtaposition of historical and modern buildings [42,43,44,45,46]. The architectural heritage from the mission hospital period in these locations is interspersed with contemporary hospital structures and is now repurposed for non-medical functions, such as administrative offices, teaching facilities, and support services [69,73]. Among these, Peking Union Medical College Hospital has recently undergone repair and renovation [74], while the historical buildings at Xiangya Hospital remain relatively isolated from newer structures. Qilu Hospital stands out for preserving a more comprehensive heritage environment, including historical buildings, streets, alleys, and public spaces, making it particularly representative of these three hospitals.

Therefore, Qilu Hospital of Shandong University (the original Shantung Christian University Union Medical College) was selected as the research object in the present study for the following reasons:

(1)

The site has essentially preserved the main buildings of the original mission hospital period, which are typical in terms of historical, artistic, and scientific values.

(2)

There is a lack of effective protection of the architectural heritage, with varying degrees of damage to the façade, decorations, and details of the buildings. At the same time, the overall utilisation rate of these architectural heritage sites is low, and some of the houses have been abandoned.

(3)

Since its construction, the site has experienced multiple renewals and reconstructions, resulting in an environment that reflects the architectural characteristics of various periods. This evolution is emblematic of the overall spatial pattern.

2.3. Methodology and Research Frame

In the present study, a combination of qualitative research methods, such as historical research, field investigation, and historic layering, was adopted, as outlined below:

(1)

Historical research: The historical research primarily involved the examination of historical documents and archival materials in English, which included drawings, magazines, and books [6,75], and historical data in Chinese, which are from the college history museum and library of QLH, to trace the development history of the original Shantung Christian University Union Medical College. This included detailing the completion dates of each building, documenting changes in building functions and uses, and creating a comprehensive timeline of the site’s architectural and functional evolution (Figure 2).

(2)

Field investigation: The field investigation included aerial photography by drones, research and mapping of architectural heritage, and surveying of the functional layout and current use of the hospital. The fieldwork resulted in architectural heritage survey photos and drone aerial photos, architectural drawings, and preservation status analysis drawings. Through comparative analysis with historical architectural drawings and historical photographs, the assessment of the intact condition of architectural heritage and the presumptive restoration of the original state were conducted. The fragmentary layers of buildings at different historical stages were revealed, thereby providing a reference for heritage protection and regeneration.

(3)

Historic layering: Building on the historical research, key milestones in the hospital’s development were identified. Using digital reconstructions of both planar and three-dimensional spaces, the hospital’s development history was reinterpreted as a narrative of spatial transformation, allowing an in-depth examination of changes in its spatial form over time. This analysis further extended to identifying historically significant landscapes and areas, highlighting essential public spaces, historic streets and alleys, and visual focal points that contribute to the site’s cultural and architectural heritage.

In addition, this paper utilised Sketchup (Version Pro 2018, Trimble Inc., Westminster, CO, USA), Rhinoceros 3D (Version 6.0, Robert McNeel & Associates, Seattle, WA, USA), V-Ray (Version 6.0, Chaos Group, Karlsruhe, Germany), Photoshop (Version CS6, Adobe Inc., San Jose, CA, USA), and other tools and techniques to present architectural aspects, including drawings, 3Ds, and future scenarios.

Based on the described research methodology, the landscape features and architectural heritage features of the heritage site were examined through the case study of the original Shantung Christian University Union Medical College, and the principles and methods of preservation and regeneration of modern mission hospitals in China were explored. The research framework is shown in Figure 3.

3. Case Presentation

Qilu Hospital of Shandong University is located in Jinan, the capital of Shandong Province. It can be traced to the Sino-US Hospital founded in 1890 by Mr. and Mrs. James Boyd Neal, the missionary physicians of the Presbyterian Church in the United States of America [47]. After the Boxer Rebellion in 1900, Christian missions in Shandong began to unite. In 1904, the American Presbyterians and English Baptists decided to jointly found a university, which included a medical school and hospital [76,77]. Over the years, the hospital evolved through various phases as mission medical colleges and hospitals, including the Shantung Christian University Union Medical College and Cheeloo College of Medicine [6,68]. Following 1949, it served as the Second Hospital of Shandong Province and later as the Affiliated Hospital of Shandong Medical University. In October 2000, it was renamed Qilu Hospital of Shandong University. Today, Qilu Hospital is a Grade 3A general hospital regulated by the National Health Commission of China and is recognised as one of China’s prominent general hospitals [68].

Over its century-long history, Qilu Hospital has experienced numerous alterations and expansions of varying scales (

Table 2. Spatial morphological changes to QLH (source: drawn by authors, based on [47,68,69]).

Time	Development Characterisation	General Plan
1900 ~ 1915	When the hospital was originally built, the area around the medical college and hospital and related missionary organisations (church, museum, etc.) was mainly a residential area, and the northern boundary of the hospital was what is now known as Guangzhiyuan Street.
1916 ~ 1934	Along with the expansion of the medical college and hospital, a number of dormitories, residences, and other auxiliary buildings were constructed on the south side.
1935 ~ 1952	During this period, the hospital expanded to the south and north, with the construction of new ward buildings, and the northern boundary exceeded Guangzhiyuan Street.
1953 ~ 2000	A number of new outpatient and ward buildings were constructed on the south and north sides of the hospital, and the original buildings were gradually converted into other functional uses.
2001 ~ 2023	Modern ward, outpatient, and emergency buildings were constructed near the city’s main roads, and the former mission hospital buildings were converted to office, teaching, and research purposes.

). The preserved architectural heritage from the mission hospital period includes key structures such as the Xinxing Building (formerly the Medical Teaching Building), Qiuzhen Building (formerly the Inpatient Building), Gonghe Building (formerly the Outpatient Building), Nanguan Church (formerly the British Baptist Church), and Guangzhi Yuan (Academy of Broad Knowledge) (Figure 4,

Table 3. QLH’s representative mission hospital heritage.

Date of Construction	Current Name	Original Function	Current Function	Photographs
1911	Xinxing Building	Medical Teaching Building	Mainly serves as the administrative office of QLH
1911	Qiuzhen Building	Inpatient Building	Administrative offices related to QLH medical students and standardised training personnel
1915	Gonghe Building	Outpatient Building	Mainly serves as the administrative office of QLH
1905	Nanguan Church	British Baptist Church	Clinical Medical Research Centre of Shandong University
1905	Guangzhi Yuan	Academy of Broad Knowledge, a museum about science history	College history museum and library of QLH

). In 2013, these buildings were designated as National Key Cultural Relics Protection Units in China, as part of the Qilu University complex, and form one of the three Historical and Cultural Districts identified in the Jinan Historical and Cultural City Protection Plan [78].

Along with the development of modern medical technology, the original mission hospital buildings are no longer able to adapt to the needs of modern healthcare. These buildings are now mainly used for office, teaching, and research purposes, while the medical functions have basically been moved to new outpatient and ward buildings close to the city’s main roads (Figure 5). In 2023, a new acute care complex was constructed at Qilu Hospital, featuring 11 floors above ground and 2 below, with a total floor area of 187,000 square meters [69]. This modern development presents new opportunities for the preservation and adaptive reuse of the hospital’s mission-era heritage, allowing for the integration of historical structures with contemporary healthcare facilities.

The mission hospital buildings have experienced numerous updates and renovations over their more than 100 years of use, with significant changes in their functional spatial layout. For example, Qiuzhen Building, a masonry structure oriented north–south with a total floor area of approximately 1034 square meters, originally served as the Outpatient Building for Shantung Christian University Union Medical College. Over time, it has served various functions, including as a doctors’ dormitory, library, health clinic, and clinical skills simulation training centre. Currently, Qiuzhen Building houses the office of QLH, managing medical students and social trainers.

Additionally, the mission hospital buildings at QLH exemplify a fusion of Chinese and Western architectural styles, often referred to as “Chinese Classical Revival” [38], “Chinese style” [37], or “hybridised buildings” [35]. These structures typically consist of two or three stories, featuring neoclassical façades with a horizontal three-section and vertical five-section composition, characterised by a sense of order and strict proportionality. Unlike the large roofs of northern China’s classical official buildings, which were common in Union Medical College at Peking and other mission hospitals of the same period [42], the QLH mission hospital buildings mainly adopt the structure and decorative details of the local traditional houses in Jinan. With the exception of the Xinxing Building, the buildings all adopt a gabled roof, clear-water grey brick walls, and traditional decorative patterns on the eaves and ridges that are common to Jinan houses.

4. Results and Discussion

4.1. Landscape Characterisation

It is widely acknowledged that the preservation and reuse of built heritage should not focus solely on the individual structures but should also consider the broader historic environment in which they are situated. According to the Recommendation on the Historic Urban Landscape, the historic urban landscape includes not only the historic and contemporary built environment but also open spaces, gardens, land-use patterns, spatial organisation, perceptual and visual relationships, and other integral elements of the urban fabric [58]. Balancing the demonstration and enhancement of architectural heritage with the fulfilment of social development and local needs offers a pathway toward achieving the sustainable development of religious heritage [79].

The preservation of mission hospital heritage extends beyond the restoration and conservation of individual structures to encompass the broader built environment. This approach involves examining how the architectural heritage’s value and significance can be sustained and enriched within its surrounding context. It necessitates a comprehensive analysis of the historic environment, including streets, alleys, landscape features, and vantage points that define the spatial and visual relationship of the buildings within their setting.

As can be seen by examining the changes in the spatial form of the hospital (Table 2), QLH was gradually expanded from a mission hospital to a large, modernised hospital. Examining the changes in the spatial form of QLH through the historic layering method, the architectural heritage of the mission hospital period is mainly located on the south side of Guangzhiyuan Street. Along with the expansion of the hospital, it gradually broke through Guangzhiyuan Street to the north side of the area and expanded to the south side to the city’s main road, where the outer city wall used to be.

The developmental changes of QLH highlight that the primary conservation area encompasses both the architectural heritage of the five former mission hospital buildings and the surrounding public spaces, historical streets, and alleys. The boundaries of this area are defined by Guangzhiyuan Street to the north, the eastern wall of Guangzhiyuan to the east, Xishuanglong Street to the west, and the southern courtyards of Qiuzhen Building and Xinxing Building to the south (Figure 6). This area includes significant landscape features, such as public spaces, historic streets and alleys, and key visual focal points, which are integral to the overall character and historical value of the site. The specific features are as follows:

(1)

Public spaces, including the garden on the south side of Qiuzhen Building (Figure 6a), the courtyard on the south side of the Xinxing Building (Figure 6b), and the courtyard between the Republican Building and the Xinxing Building (Figure 6c). Among them, the garden on the south side of Qiuzhen Building is a late-designed Chinese garden landscape, while the other two public spaces are used as motorised and non-motorised parking lots, which affects the spatial quality.

(2)

Historical streets and alleys, including Guangzhiyuan Street (Figure 6f), the street on the west side of Guangzhi Yuan (Figure 6d), and Xishuanglong Street (Figure 6g). These three streets basically maintain the original spatial scale and interface.

(3)

Visual focal points, including the view corridor facing the entrance of Guangzhi Yuan (Figure 6e), the east elevation of the Gonghe Building (Figure 6f), and the south elevation of the Xinxing Building (Figure 6b). These three nodes are important display surfaces of the architectural heritage and should be presented with appropriate strategies in the subsequent regeneration.

4.2. Landscape Renewal and Space Improvement

In response to the landscape characteristics of the built heritage identified above, various strategies can be employed to foster landscape renewal and spatial enhancement. These strategies not only address the intrinsic value of the built heritage itself but also consider the distinctiveness and cultural significance of the surrounding environment [62]. In addition, these strategies also involve the demonstration of heritage values, the improvement of the environment of the heritage site, and the participation of the residents of the heritage site. The aim is to increase the closeness between users and the built heritage and to enhance the richness of the heritage site experience, thus integrating the built heritage into local life [62]. This paper outlines four strategies for landscape renewal and enhancement: maintenance, partial renewal, reinforcement, and creation (

Table 4. Spatial renewal strategies for the built heritage and landscape of QLH (source: drawn by authors).

Location	Renewal Strategy	Intentions	Specific Measures	Current Photo	Spatial Intention
South Courtyard of Qiuzhen Building	Maintenance	Enhancement of the expression of heritage values	Appropriate tree trimming to showcase the south elevation of Qiuzhen Building
South of Guangzhiyuan Street	Partial Renewal	Demonstration of heritage values and provision of rest spaces	Tidy up the streetscape and provide leisure seating
Courtyard between Gonghe and Xinxing Building	Partial Renewal	Environment improvement and shaping of public spaces	Tidy up the green landscape and restrict the parking of vehicles
Entrance to Guangzhi Yuan	Reinforcement	Enhancement of visual guidance	Provide corridors on both sides of the road to strengthen the visual guidance towards Guangzhi Yuan
East Elevation of Gonghe Building	Reinforcement	Demonstration of heritage values and provision of public spaces	Installation of urban furniture to provide a viewing point for the west elevation of Gonghe Building
North of Guangzhiyuan Street	Creation	Promoting pedestrian and vehicle segregation	Add leisure corridors on the north side of Guangzhiyuan Street
South Courtyard of Xinxing Building	Creation	Expansion of public space and improvement of healthcare environment	Redesign the courtyard on the south side of Xinxing Building to integrate with the landscape on the east side

). The specifics of these strategies are detailed as follows:

(1)

Maintenance refers to the existing heritage and its environment; retaining the heritage and landscape spatial characteristics and maintaining the status quo is the main focus in the subsequent renewal. For example, the south courtyard of Qiuzhen Building, which is a Chinese garden landscape constructed at a later stage, has become a public leisure space in the hospital. By maintaining the courtyard space within the hospital, a hospital “backyard” for recreation can be created for patients, thus contributing to the enrichment of their daily lives.

(2)

Partial renewal refers to the approach where the existing heritage and its surrounding environment largely preserve the original spatial characteristics of the site. The quality of the space can be enhanced through municipal management, landscaping, greening, and other localised interventions. For instance, the courtyard between Gonghe Building and Xinxing Building, which reflects the spatial scale and boundary interface of the historical structures, could undergo partial renewal through measures such as landscaping, greening, and restricting vehicle parking to improve the overall environment while maintaining its historical integrity. Through the strategy of partial renewal, the transportation connectivity between built heritage can be enhanced, and some public space nodes around the built heritage can be shaped to enhance the experience of the hospital environment.

(3)

Reinforcement involves enhancing both the heritage and landscape value through targeted landscape renewal and spatial transformation. For example, the east elevation of Gonghe Building, which reflects the compositional characteristics of a Western Gothic church, faces Guangzhiyuan Street and holds significant heritage display value. To reinforce this, a public corner space could be created on the north side of Guangzhiyuan Street, providing a place for people to pause, relax, and engage with the heritage value of the site. This intervention would not only highlight the building’s architectural features and promote the spatial orientation of heritage sites but also enhance the public’s connection to the historical context.

(4)

Creation involves the design of urban furniture, vignettes, and recreational spaces to introduce new forms of experience and interpretation within historic landscapes. For instance, Guangzhiyuan Street, a historic thoroughfare dating back to the mission hospital period of QLH, leads to the eastern entrance of the site. Along its southern side, a sequence of historic buildings, including Guangzhi Yuan, Nanguan Church, Qiuzhen Building, and Gonghe Building, forms a continuous architectural backdrop. To enhance connectivity and visitor experience, a stormwater corridor could be installed on the northern side of the street. This would not only improve accessibility for patients but also provide viewing spaces that frame the old buildings, enhancing the interpretive value of the heritage site. Additionally, new structures and spatial nodes could be introduced to strengthen or redefine the landscape character while ensuring that these interventions remain in harmony with the existing environment. The strategy of creation also serves to strengthen the bond between the heritage site and the people of the community, promoting openness and public access to the mission hospital heritage.

Through the above strategies for landscape renewal and enhancement, the aim is to enhance the relevance between users and the built heritage. There are three specific aspects. Firstly, it enhances the presentation of built heritage values. Trimming trees and shaping public space nodes can provide more viewpoints for the built heritage. This presents the complete façade of the architectural heritage to the public and realises the transmission of historical and artistic values. Secondly, it can create leisure spaces for patients. Through the strategy of upgrading the environmental quality, the hospital “backyard” can be shaped for the relaxation of patients. This approach also creates a well-scaled and beautiful courtyard landscape, which contributes to the rehabilitation of patients. Finally, this provides public activity spaces for the community. Relying on roads and street corners to shape recreational spaces can provide some experiential spaces for the neighbouring residents. This strategy also helps to strengthen the connection between heritage sites and community residents.

4.3. Architectural Heritage Characterisation and Preservation Strategies

The spatial patterns of architectural heritage have also been altered by successive renovations. For example, Qiuzhen Building features one-floor east and west wings, with a two-floor central section (Figure 7a,b). When it was originally constructed, it adopted a modern medical and surgical layout (Figure 8a). In line with this functional design, two main entrances were placed on the north façade: one for medical patients and the other for surgical patients. The central protrusion of the building to the north was designed as a waiting room, around which various medical departments were distributed. A podium at the centre of the waiting room was used by the church for preaching, reflecting the mission hospital’s dual medical and religious function. The surgical section on the east side was designed with a separate flow for medical staff, reflecting the modern hygienic practices of the time.

In contrast, the building has since been repurposed for office use, with an east–west internal corridor (Figure 7d,e). The internal spatial structure has been altered so extensively that the original layout is no longer recognisable (Figure 8b). Despite these internal changes, the building’s exterior largely retains its original style and form. For example, the south elevation originally featured an open corridor facing the garden, though only part of it remains today (Figure 8c,d). Additionally, the original side entrances on the north elevation (Figure 8e,f), designed for triage, are no longer in use, and the main entrance has been relocated to the southwest corner of the south façade (Figure 7c).

Based on the described analysis, the preservation of the mission hospital heritage needs to return to the historical context and examine the historical and cultural elements therein. This relates to the modernity of medical care embodied in the architectural heritage of the mission hospital [28]. For instance, Qiuzhen Building has a spatial structure that separates the medical and surgical departments, as well as a separate flow line for the operating room, a sterilisation space, and an operating theatre. At the same time, as a mission hospital, it serves the dual roles of medical care, relief and charity, and religious preaching [29]. Thus, it incorporates religious elements into the architectural space. Qiuzhen Building is located next to Nanguan Church, and the layout reflects the interdependence of Christianity and medical space. The original spatial structure of Qiuzhen Building, which reflected the church’s preaching function in the waiting room, should be acknowledged as a key aspect of its significance.

Further, preserving heritage is not limited to maintaining its original state but also involves enhancing its potential for adaptive reuse. Every functional reorganisation must address the building’s historical, material, and spatial transformations while identifying and safeguarding the elements that contribute to its value [80]. In the case of the mission hospital buildings, they are no longer able to adapt to the needs of contemporary healthcare development, and the shift in function has become irrevocable. In this case, the continuation of the existing office use is a reasonable alternative. Office use requires relatively less modern equipment and facilities, which reduces the intervention in the architectural heritage itself. In addition, the future development trend of hospital buildings has transformed from single medical use to integrated use of medical, teaching, and research [81]. Such functions as teaching, research, and related management are also reasonable options. It is important to note that they can be transformed into functional spaces that can serve new purposes while respecting their historical integrity [82].

Given the significant changes to the internal functional spaces of the mission hospital buildings, their architectural appearance and style have become the primary focus of preservation. Taking Qiuzhen Building as an example, the façade incorporates decorative elements typical of Western neoclassical architecture, including stone window covers, abstract classical columns, arched windows, keystones, and other detailing (Figure 9h–n). The building also adopts several details of traditional houses in Jinan, including huatong ridges, brick carvings, carved stone boards, hanging fish motifs, brick slabs, tiled ridges, and upturned roof ridges (Figure 9a–g). These decorative details, which are a fusion of Chinese and Western architectural cultures, should be preserved as a priority. The decorative elements of the building should be properly protected, especially the huatong ridge and brick slab, which need to be repaired according to the original workmanship. It should also be determined whether the climbing plants on the surface of the wall are a potential threat to the heritage to ensure that the elements of value will not be damaged.

4.4. Preservation and Regeneration Principles for Mission Hospital Heritage

Based on the described analysis and discussion of the landscape characteristics and architectural heritage features of the QLH mission hospital heritage, the present authors believe that an integrated and systematic principle and approach is needed in preserving and utilising the architectural heritage of mission hospitals. The principles and methods are as follows:

(1)

Modern mission hospitals are generally architectural complexes and landscapes composed of multiple buildings and their surroundings. Research utilising historical data, historical maps, and satellite imagery should be employed to trace the development of the spatial form of these mission hospitals. This research should focus on refining the understanding of the landscape environment, public spaces, historic streets, and visual focal points of historical significance. In addition, historical research is intended to promote the sustainable development of mission hospitals and the intergenerational transmission of value elements.

(2)

Emphasis should be placed on the overall preservation and spatial enhancement of the buildings, landscape, and environment of the heritage site of the modern church hospital. Strategies such as maintenance, partial renewal, reinforcement, and creation should be comprehensively adopted to expand the value interpretation of built heritage and environment. The enhancement of the spatial environment of the mission hospital heritage site can also help to shape recreational and experiential activities and improve the performance of the healthcare environment. In addition, the shaping of public space at heritage sites can provide opportunities for local communities to experience heritage values and promote heritage justice. For example, the present study studied the landscape characterisation and spatial renewal strategies of QLH mission hospital heritage, aiming to enhance the recreational, public, and healthcare functions of the heritage site. This will help to improve the participation and experience of people in the heritage site [62].

(3)

The integrity of the architectural style of modern mission hospital buildings must be given due attention, particularly when functional transformations are unavoidable. In such cases, the fusion of Chinese and Western architectural styles, along with the artistic features, decorative details, and structural elements reflected in the buildings, should be preserved and carefully restored. This hybridisation, which represents a unique cultural synthesis, is integral to the buildings’ historical and architectural significance, and preserving these elements will ensure that the buildings retain their distinctive character and cultural value. For example, in Qiuzhen Building, the decorative details of Western neoclassical architecture and traditional houses in Jinan should be preserved as a priority.

(4)

The reuse of the architectural heritage of mission hospitals should be guided by the need for the synergistic development of medical care, education, and research in contemporary hospitals. Adaptive reuse is a pragmatic strategy designed to repurpose mission hospital heritage that has lost its original function, allowing it to be integrated into new environments and continue to serve contemporary needs. This approach necessitates a thorough physical and functional reassessment of the built heritage, ensuring that the historical memory and identity embedded in the space are preserved, even as elements related to its original social and health functions are modified or removed [83]. Through adaptive reuse, the cultural and architectural significance of the heritage is maintained while facilitating its continued relevance and utility in a modern context.

(5)

The architectural heritage of mission hospitals is a non-renewable resource, necessitating a holistic and multidisciplinary approach to its preservation. Such an approach ensures consistent decision-making and effective practices. The goal of adaptive reuse is to preserve, rather than simply isolate, the heritage in a static state [84]. New, viable functions must be carefully chosen to align with the existing architectural fabric, ensuring compatibility with the original structure. Materials used for the consolidation and restoration of mission architectural heritage should focus on compatibility and reversibility to ensure that interventions have low impacts on the built heritage. Less intrusive strategies should be prioritised, allowing the heritage to retain its historical spatial integrity while fostering a reconnection with its surrounding region and community. This approach allows the building to evolve while maintaining its cultural and architectural significance.

5. Conclusions

The modern mission hospital is a significant form of architectural heritage, embodying the cultural exchange between China and the West, as well as the evolution of modern medicine during China’s process of modernisation. As the hospital type has evolved and medical technologies have advanced, the original mission hospital buildings can no longer meet the needs of contemporary healthcare, making the transformation of their functions an inevitable trend. In this context, the preservation and adaptive reuse of mission hospital architecture has become a widely discussed issue. In the present study, the methods of landscape characterisation and architectural heritage characterisation of mission hospitals were examined through a case study of the original Shantung Christian University Union Medical College. Principles of landscape renewal, spatial enhancement, and heritage preservation and regeneration were also proposed with a view to informing the study regarding the preservation and regeneration of this type of heritage. The main aim of this approach was to interpret the value of mission hospital heritage to the public and to make these buildings better serve contemporary social life. The core idea is that the preservation of mission hospital heritage does not only imply the conservation of a single building but also the historical environment and landscape in which it is situated as a whole. For individual buildings, the focus of preservation should be on their architectural style, artistic features, and decorative details. These elements are key to understanding the early mission architects’ efforts to blend Western design with Chinese and local cultural contexts, and they represent a vital part of the cultural and historical narrative of these buildings.

Since China’s Reform and Opening Up, along with the rapid development of urbanisation, many urban historical heritage sites have encountered difficulties. In some heritage sites, excessive commercialised development has brought negative effects on the original cultural atmosphere and historical value. Some architectural heritages have inevitably suffered the fate of being remodelled or demolished. Compared with other types of urban architectural heritage, hospital heritage is faced with the dual dilemma of urbanisation and medical technology advancement. This calls for a re-examination of the historical, cultural, and social values of hospital heritage and an exploration of diversified ways of preservation and reuse. It is important to note that hospital heritage is an important resource for shaping the character of contemporary cities and helping future generations to understand the past. Therefore, we should cherish and protect the heritage of these hospitals and promote their sustainable development so that they can continue to play a positive role in the new era. The reuse aspect of the architectural heritage of mission hospitals also involves the relationship between new functions and old structures, new materials and old materials, and new equipment and old spaces, which are important strategies to promote the sustainability of the mission hospital heritage. This will be the focus of the next research work.