1.   I was able to breathe only with the utmost difficulty, and my arm hurt like hell.

2.   Uncivilised tribes, surrounded by magnificent scenery, have the utmost difficulty in receiving the simplest moral and intellectual concepts.

3.   When she wore the collar, she ate only with the utmost difficulty.

4.   She said even less and was, in fact, having the utmost difficulty in trying to be natural with him.