No. 26
OBSTRUCTING A HIGHWAY

(Title)

1. The defendant wrongfully dug a trench and heaped up earth and stones in the public highway leading from …… to …… so as to obstruct it.
2. There by the plaintiff, while lawfully passing along the said highway, fell over the said earth and stones [or into the said trench] and broke his arm, and suffered great pain, and was prevented from attending to his business for a long time, and incurred expenses for medical attendance.
   [As in paras 4 and 5 of Form No. 1, and relief claimed.]