It required some degree of skill to strike a vein properly. The most common vein tapped was in the elbow, although veins in the foot were also popular. The arm was first rubbed and the patient given a stick to grasp. Then a tourniquet would be applied above the elbow (or, if the blood was to be taken from the foot, above the ankle), in order to enlarge the veins and promote a continuous flow of blood. Holding the handle between the thumb and the first finger, the operator then jabbed the lancet into the vein. Sometimes, especially if the vein was not close to the surface of the skin, the instrument was given an extra impetus by striking it with a small mallet or the fingers to insure puncturing the vein.[53] The incisions were made diagonally or parallel to the veins in order to minimize the danger of cutting the vein in two.[54] For superficial veins, the vein was sometimes transfixed, that is, the blade would be inserted underneath the vessel so that the vessel could not move or slip out of reach. The transfixing procedure ensured that the vein would remain semi-divided so that blood would continuously pass out of it, and that injury to other structures would be avoided. Deep-lying veins of the scalp, for example, could not be transfixed. They were divided by cutting through everything overlying them since there were no important structures to injure.[55] The consequences of puncturing certain veins incorrectly were discussed by many early writers including Galen, Celsus, Antyllus, and Paul of Aegina.[56] Injury to a nearby nerve, muscle, or artery resulted in convulsions, excessive bleeding, or paralysis. Bloodletting was at its most fashionable in the eighteenth and early nineteenth centuries. In this period it was considered an art to hold the lancet properly and to support the arm of the patient with delicacy and grace.[57] Many patients had by repeated bloodlettings become inured to its potential danger and unpleasantness. In the mid-eighteenth century one British physician declared: "People are so familiarized to bleeding that they cannot easily conceive any hurt or danger to ensue, and therefore readily submit, when constitutional fear is out of the question, to the opening of a vein, however unskillfully advised."[58] In England in the early nineteenth century people came to the hospital to be bled in the spring and fall as part of the ritual for maintaining good health. At some periods there were so many people undergoing prophylactic bloodletting that they could be seen lying on the floor of the hospital while recovering from the faintness induced by venesection.[59] The lancet was perhaps the most common medical instrument. _The Lancet_ was the name of one of the oldest and most socially aware English medical journals, founded by Thomas Wakeley in 1823.[60]