Is 26.2 miles simply too much for one person to bear?

Well, as the crowds amass Sunday on the Verrazano Bridge to begin New York City’s 44th marathon, it might be time to rethink the healthiness of the entire endeavor. Clearly the orthopedic wear-and-tear is sufficient to keep an entire generation of orthopedic surgeons and physical therapists booked wall-to-wall. But recently there have been several high-profile articles (here and here) suggesting maybe the entire enterprise is medically unhealthy too. One, from The Wall Street Journal, has the unexpectedly lighthearted title, “The Exercise Equivalent of a Cheeseburger?”

If indeed that headline rings true, it's easiest to blame Phidippides, the Greek long-distance runner whose 26-mile scamper 2,500 years ago from the town of Marathon to Athens set the macho tone and the literal distance for the modern marathon.

The story, which is probably not completely untrue, goes like this: a few days earlier the same Phidippides, a professional courier who hurried from here to there, had made a round trip from Marathon to Sparta (measuring about 280 miles) to beg the Spartans for help against an upcoming Persian attack. Then, after an unlikely Athenian victory (sans Spartans, who needed to wait till a full moon passed), the Athenians dispatched the same Phidippides from Marathon off to central HQ in Athens to forewarn the hometown that the routed Persians had regrouped and were about to attack Athens directly.

Heroic, right? There's one wee problem—once he arrived with the big news and said something like, “Joy to you; we have won!”, ‎Phidippides fell over dead. From exhaustion.

That’s right. The winner of the first marathon (OK, he was the only runner, but still) died from the effort. You might think that such a story would become a cautionary tale.

You might also think to find a cautionary tale in the recent spate of articles raising questions about the sport. These articles use a base of epidemiologic data, including a recent article from the New England Journal of Medicine on the topic to suggest that older men are at substantially higher risk for sudden marathon-related cardiac death than younger runners or women. Furthermore, The New England Journal article suggested an increasing rate of death in marathon men over the past few years.

The reason—if the finding is true—might be that the exceptional exertion of the race strains the heart enough to cause low-grade, ongoing inflammation and even a “leak” of heart muscle cells. This theory is akin to the explanation given for why leg muscles ache the day after you run or hike or hurry too much: that ache is caused by inflammation. Over time, the theory goes, inflammation causes trouble—plaques and less pliable arterial walls. (Warning: “too much inflammation” is the current explanation in clinical medicine for just about every malady, suggesting that we might be overplaying our hand).

There is no direct evidence for this—autopsies of those dozens who have died in mid-marathon have shown an array of defects, particularly “hypertrophic cardiomyopathy,” a seemingly unprovoked thickening of heart muscle that has been cited in the sudden deaths of many athletes, including basketball players Hank Gaithers and Reggie Lewis. But hypertrophic cardiomyopathy is not known or hypothesized to arise after constant low-grade inflammation, so the actual finding and the maybe-theory fail to align.

Other autopsy findings from those who die while running include clinically inapparent hardening and narrowing of the arteries that, under the unusual strain of those 26 miles, proves too much to supply the wildly beating heart. James Fixx, whose book The Complete Book of Running was something of the original call to arms for Jogger Americanus, famously died at age 52 while running. He was found at autopsy to have severe hardening of his coronary arteries.

By my assessment, there is evidence that a certain very small group of marathoners do indeed take on real health risk by pushing their particular envelope too far, but the net benefit of exercise for the population at large vastly outweighs the downside for those few who invite danger by toning up.

So, sorry. The nausea so many feel from observing today’s spectacle of American extremism, the parade of self-improvement and self-realization and self-actualization and just plain old self-ness, falls far short of a workable alibi to allow us to turn away from the boring and less dramatic exercise routine necessary for modern man. Rather than embracing the example of poor Phidippides, though, we all might be better suited pledging our allegiance to another ancient Greek, Sophrosyne, the goddess of moderation.