或发热极甚，而恐承气不能退者；或已下后而热不退者；或蓄热内甚，阳厥
极深，以阳气怫郁不能营运于身表四肢，以致通身清冷、痛甚不堪、项背拘急、
目青睛疼、昏眩恍惚、咽干或痛、躁渴、虚汗、呕吐、下利、腹满实痛、烦冤闷乱、喘急、郑声、脉虽
疾数，以其蓄热极深而脉道不利，反致脉沉细而欲绝，俗未明其造化之理，而反谓其伤寒极阴毒者；或
始得之，阳热暴甚而便有此证候者；或两感热势甚者，通宜解毒（二十一）加大承气汤（十）下之，热
不退者宜再下之。虽古人云∶三下之而热未退即死矣。然亦有按法以下三、五次，利一、二十
行，热方退而得活者，免致不下退其热而必死也。下后热少退而未愈者，黄连解毒汤调之。或失下热极，
以致身冷、脉微而昏冒将死者，若急下之，残阴暴绝而死。盖阳气后竭而然也，不下亦死，宜凉膈散（二十
三）或黄连解毒汤，或二药合服，或白虎（二十二）合凉膈散，养阴退阳，积热渐以宣散，则心胸温暖，脉渐以
生，至于脉复有力，方可以三一承气汤（十三）下之，或解毒加六一散（五十二）调之，愈后宜服退热
之药，忌发热诸物。里热脉厥者，宜白虎汤。热极厥深而诸药下毕，竟不能利者，不救必死，黄连解毒
汤更加甘遂末一钱匕下之。
有的患者发热极其严重，担心承气汤无法退热；有的患者已经使用下法后热势仍未消退；有的是体内蓄积的热邪极盛，导致阳厥（因热邪内闭，阳气不能外达四肢而出现的四肢逆冷证）程度极深。由于阳气被郁结阻滞，不能在体表和四肢运行，从而导致全身清冷、疼痛剧烈难以忍受、颈项和背部拘急僵硬、眼睛发青且眼球疼痛、头晕目眩、神志恍惚、咽喉干燥或疼痛、烦躁口渴、出虚汗、呕吐、腹泻、腹部胀满且按之疼痛、心烦意乱、呼吸急促、说胡话（郑声）。虽然脉搏疾速细数，但因为蓄积的热邪极深，导致脉道运行不畅，反而出现脉象沉细微弱几乎摸不到的情况。世俗之人不明白这种病机转化的道理，反而认为这是伤寒中极重的阴毒证。
有的患者刚得病时，阳热突然极盛就出现了这些证候；有的是两感病（同时感受表里两经之邪）且热势严重的，都适宜使用解毒汤加大承气汤来攻下。如果热势不退，应当再次攻下。虽然古人说：“经过三次攻下而热势未退的就会死亡。”然而也有按照方法连续攻下三到五次，排便一二十次后，热势才消退而得以存活的情况，以免因为不及时攻下退热而导致必然死亡。
攻下之后，热势稍微减退但尚未痊愈的，用黄连解毒汤调理。如果是误失了攻下的时机导致热邪极盛，以至于身体冰冷、脉微细、神志昏迷濒临死亡的，如果急于攻下，残存的阴液会骤然断绝而死。这是因为阳气随后耗竭所致。如果不攻下也会死亡，适宜使用凉膈散或黄连解毒汤，或者两药合服，或者白虎汤合凉膈散，以滋养阴液、消退阳热，使积聚的热邪逐渐宣散，那么心胸就会感到温暖，脉象逐渐恢复，直到脉搏重新变得有力，这时才可以使用三一承气汤攻下，或者用解毒汤加六一散调理。病愈后适宜服用退热的药物，忌食引起发热的食物。
如果是里热导致的脉厥（脉象与症状不符，如身热而脉沉伏），适宜使用白虎汤。如果热邪极盛、厥逆极深，各种攻下药都用过了，竟然仍然不能通便的，属于不治之症，必然死亡；此时可用黄连解毒汤加入甘遂末一钱匕进行攻下。
In cases where the fever is extremely severe, and there is concern that Chengqi Tang (Cinnamon Twig and Rhubarb Decoction) may not be able to reduce the heat; or in cases where the heat persists even after purgation has been administered; or in cases where excessive heat is accumulated internally, leading to a profound Yang Jue (cold extremities due to internal heat blocking yang qi circulation), such that the yang qi is constrained and unable to circulate to the body surface and limbs, resulting in coldness of the entire body, unbearable severe pain, stiffness and tension in the neck and back, cyanosis of the eyes with ocular pain, dizziness, mental confusion, dry or painful throat, irritability and thirst, spontaneous sweating, vomiting, diarrhea, abdominal distension with solid pain, vexation and restlessness, rapid breathing, and delirious speech. Although the pulse may be rapid and fine, because the accumulated heat is extremely deep and obstructs the pulse vessels, the pulse may paradoxically appear deep, fine, and nearly imperceptible. Laypeople, failing to understand the transformative nature of this pathology, often mistakenly diagnose it as an extreme Yin-toxic condition in Cold Damage.
In cases where, upon initial onset, yang-heat suddenly becomes extremely intense presenting with these symptoms; or in cases of Lianggan (simultaneous involvement of exterior and interior meridians) with severe heat intensity, it is generally appropriate to use Jiedu Tang (Detoxification Decoction) combined with Da Chengqi Tang (Major Order to Preserve the Yield Decoction) to purge. If the heat does not subside, purgation should be repeated. Although ancient texts state: "If heat remains after three purgations, death ensues," there are instances where, following proper protocol, three to five purgations were performed, resulting in ten to twenty bowel movements, after which the heat subsided and the patient survived, thereby avoiding certain death from failure to purge the heat.
After purgation, if the heat slightly subsides but recovery is incomplete, Huanglian Jiedu Tang (Coptis Detoxification Decoction) should be used for regulation. In cases where purgation was missed, leading to extreme heat, causing coldness of the body, minute pulse, and coma approaching death, immediate purgation would cause the residual yin fluids to abruptly cease, leading to death due to subsequent exhaustion of yang qi. Without purgation, death also occurs. In such scenarios, it is appropriate to use Liangge San (Cooling the Chest Powder) or Huanglian Jiedu Tang, or a combination of both, or Baihu Tang (White Tiger Decoction) combined with Liangge San, to nourish yin and retreat yang, allowing the accumulated heat to gradually dissipate. As a result, the chest and heart will feel warm, and the pulse will gradually reappear. Only when the pulse regains strength can Sanyi Chengqi Tang (Three-One Order to Preserve the Yield Decoction) be used for purgation, or the condition can be regulated with Jiedu Tang plus Liuyi San (Six-to-One Powder). After recovery, antipyretic herbs should be taken, and foods that induce heat should be avoided.
For Nei Re Mai Jue (interior heat manifesting as pulse jue), Baihu Tang (White Tiger Decoction) is appropriate. In cases of extreme heat and profound jue where all purgative medicines have been exhausted and bowel movement still cannot be achieved, the condition is incurable and leads to death; in this desperate situation, Huanglian Jiedu Tang (Coptis Detoxification Decoction) with one qianbi of Gansui powder added can be used for purgation.