= Solution
\b[The historical priorities were rest, relief of painful <arthritis>, and repeated examination for <carditis>; modern treatment also eradicates preceding <streptococcal infection> and prevents recurrences.] In an 1865 account, the patient would be nursed in bed, the painful <anatomical joints> supported, drinks and tolerable nourishment supplied, and temperature, pulse, breathing and <urine> observed. Moist flannel applications and <opium> preparations were used for severe pain and sleeplessness. Alkaline salts were commonly prescribed under a theory that the disease involved an abnormal acid material; attempts to make the <urine> alkaline were a therapeutic practice, not proof that an acid caused the disease. There was already disagreement about the value of specific drugs and <blistering agents>. A contemporary critique describes these competing treatments and stresses the inadequacy of small uncontrolled case series.<Remarks on the treatment of acute rheumatism in the British Medical Journal (1865)>[14 January, p. 31, ordinary management and criticism of blistering]{ref}
The important complications are <rheumatic carditis>, including <valvulitis> and sometimes <pericarditis>, with possible <heart failure>; <Sydenham's chorea> is another manifestation. New <dyspnoea>, a changed <heart murmur>, chest pain, a <pericardial friction rub>, or signs of circulatory failure require reassessment rather than stronger treatment of the painful <anatomical joint> alone. Historically, local bleeding, <Mercury> and <counterirritation> were employed against supposed cardiac inflammation. Their historical use does not justify them now. A heart examination also matters when <arthritis> improves, because improvement of pain does not establish freedom from cardiac injury.<Clinical Guidance for Acute Rheumatic Fever by CDC>[clinical manifestations: carditis, arthritis and chorea]{ref}
Present management confirms the diagnosis and cardiac involvement with appropriate clinical criteria, <electrocardiography> and <echocardiography>. <Penicillin> or an appropriate alternative eradicates residual group A <Streptococcus>[streptococci], even if the throat symptoms have resolved. An <anti-inflammatory drug> relieves <arthritis>; severe <carditis>, <heart failure> or disabling <Sydenham's chorea> needs specialist management. Fluid-retaining <heart failure> can require a <diuretic> with monitoring of renal function and <electrolytes>; treatment is selected according to haemodynamic findings. The 2025 guideline allows <corticosteroids> for selected severe <carditis> or <pericarditis> with effusion, under specialist care. Mild <Sydenham's chorea> may need only rest and a calm environment; greater functional impairment can justify <carbamazepine> or another carefully selected symptomatic medicine. These measures accompany, rather than replace, <antibiotic prophylaxis>. <Secondary antibiotic prophylaxis> reduces future attacks and further valve injury. Neither <aspirin> nor a later <salicylate> regimen should be presented as ordinary Oxford practice in 1865. These are historical explanations and general medical principles, not a treatment plan for an individual.<Australian guideline for acute rheumatic fever and rheumatic heart disease (2025)>[acute management, cardiac assessment, management of chorea and secondary prophylaxis]{ref}
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