During the jury trial which led to the defendant’s conviction of statutory rape 1 and indecent assault and battery on a child under fourteen, 2 three categories of evidence were received: the testimony of the complainant; the fresh complaint testimony of the complainant’s mother; and medical records from two hospitals at which the complainant was examined. A principal ground for reversal urged on appeal — we think persuasively — is that it was error to admit so much of a hospital record as recited, “Diagnosis: Sexual molestation.” We also consider a problem of legibility, the sufficiency of the evidence, and a sentencing issue.
When the alleged crimes occurred, the complainant was ten years old 3 and lived with her mother, the defendant (who was her stepfather), and six siblings. There was evidence of incidents of molestation around Thanksgiving of 1974 and on a night in February, 1975. The indictments as to which the jury returned verdicts of guilty pertained to the 1975 events; as to the 1974 occasion or occasions, the jury acquitted. After hearing from her child about the February incident, the complainant’s mother took her for examination to Carney Hospital. Such was the child’s resistance to examination of her genitalia that no entries appear in the record from which a significant inference could be drawn. The troublesome material, admitted over timely objection, appears on the first page of a medical record compiled two days later, when the child was reexamined at Harrington Memorial Hospital in Southbridge.
1.
Admissibility of diagnosis of “sexual molestation.”
The statute which authorizes the admission of hospital records, so far as they relate to “treatment and medical history,” excludes material “which has reference to the question of liability.” G. L. c. 233, § 79. If, as
Commonwealth
v.
Gardner,
In the instant case, the Harrington Memorial Hospital record unqualifiedly stated a “diagnosis” of “sexual molestation,” a term synonymous to laymen with indecent assault and battery, one of the crimes with which the defendant was charged. Unlike the circumstance in
Commonwealth
v.
Rembiszewski,
The diagnosis in the Harrington Memorial Hospital record was not an expert opinion that the physical facts indicated that the victim had “most probably” been assaulted by an attempt at penile insertion,
Commonwealth v. van Kooiman,
2.
Illegible record entries.
As a general rule, it is well to excise illegible portions of hospital records admitted under G. L. c. 233, § 79.
Commonwealth
v.
Brattman,
Vag. Clean cx not seen Hymen tight, IF c evidence of healing lac at 10 o’c ut. ting. No ola masses
Illegibility is a relative matter and there must be broad discretion in the trial judge to determine in a particular case whether writing in a hospital record can be read and decoded. Defense counsel objected that the entry in question was not legible but in closing argument translated it (apparently anticipating the prosecution’s closing argument) to mean: “Vagina clean cervix not seen hymen tight, one finger with evidence of healing laceration at ten o’clock.” 4 While admission of the entry set out above was perhaps within the limits of the allowed discretion, it would seem better, in the event of a new trial, to have stipulations as to the meaning of the abbreviations and symbols, to have the physician who made the entry explain them (an unlikely possibility in view of the antiquity of the entry and subversive of the purpose of the statute, i.e., to obviate the need for doctors and nurses coming to court 5 ), or to exclude the entry.
3.
Sufficiency of the evidence as to rape.
Concerning the November, 1974, episode, the victim testified to digital penetration. The jury, however, returned verdicts of not guilty on
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the indictments arising out of events in 1974. In connection with the episode of February, 1975, the victim’s testimony was uncertain and the defendant argues on appeal that it did not support a finding of guilt as to statutory rape.
6
At trial the defense had not moved for a required finding of not guilty, but a finding “based on legally insufficient evidence [is] inherently serious enough to create a substantial risk of a miscarriage of justice.”
Commonwealth
v.
McGovern,
About the February, 1975, incident, the complainant had testified that her stepfather “got up on top of me” and “tried to put his penis inside of me.” He had not, she said, succeeded, although the attempt had lasted ten minutes. He had “used [vaseline] to put it around in my vagina” with his finger. As to whether the defendant had inserted his finger in her when he was putting the vaseline on, the complainant replied: “I don’t remember. I think so, just like around it and stuff.”
The jury did not, nor was it required to, make a specific finding whether penile or digital penetration had occurred. A statutory rape indictment encompasses unnatural as well as natural sexual intercourse,
Commonwealth
v.
Gallant,
Intrusion into the vagina itself is not required to make out the wrongful penetration. Touching by the male of the vulva
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or labia, as may surely be inferred from spreading vaseline and ten minutes or so of attempted penile penetration, is intrusion enough. See
Commonwealth
v.
Mosby,
4.
Sentencing.
Baldwin claims that the trial judge sentenced him as a second offender, although he was not so charged. If a defendant is to be subject to a prescribed statutorily enhanced penalty because of a former conviction, the complaint or indictment must state that a second, third, etc., offense is involved.
Commonwealth
v.
Harrington,
Each sentence was within the statutory limits prescribed in G. L. c. 265, § 23 and § 13B, respectively, for first offenders. All the cases resulting in reversal on the
Harrington
principle, i.e., that the defendant was treated as a repeat offender when not so charged, arose when the punishment exceeded the statutory maximum for the first offense. See
Tuttle v. Commonwealth, 2
Gray 505 (1854);
Garvey v. Commonwealth,
For the reasons stated in part 1, above, the judgments are reversed and the verdicts are set aside.
So ordered.
Notes
G. L. c. 265, § 23.
G. L. c. 265, § 13B.
For reason not altogether clear from the record, trial occurred some nine years after indictments were returned in 1976, and some ten years after the events. The complaining witness was, thus, twenty-one by the time she testified.
No one attempted an interpretation of the last line of notes or attempted to draw inferences from it.
See
Bouchie
v.
Murray,
Sufficiency of the evidence as to indecent assault and battery is not in contest.
See G. L. c. 265, § 23. Section 13B of c. 265 also provides for enhanced ' punishment for repeat offenses.
