In the case of houses backing onto, or near to, the old London streams - the Fleet, the Wandle, the West Bourne, the Ravensbourne, the New, the Holbourne (whence Holborn) and many others, which had been partly or wholly covered over - the domestic closets discharged directly into the streams. Since those on the south side were mostly tide-locked, draining into the Thames only at low tide, the results are better imagined than described; however, much of London's drinking water was still extracted from the Thames, in many cases downstream from the sewage discharge points.

The disorganized state of London's administration frustrated all attempts to deal with this growing problem. In the early 19th Century, there were no less than eight independent Commissioners for Sewers, each concerned only with their own districts.

In addition to typhoid fever, cholera reached England from the east in 1832, (over 14,000 cases in a population of 1.7 million). Following this, the new Poor Law Commission under Edwin Chadwick, the great social reformer, published its "Report on the Sanitary Condition of the Labouring Population of Great Britain" in 1842 which identified the source of the diseases as contaminated drinking water.

In 1847, spurred on by Chadwick's report, the newly-formed Metropolitan Commission for Sewers published a survey of London's sanitary arrangement above and below ground, but there was still no unified authority created. Amongst other results of this survey was the banning of the use of London's cesspits and the provision of flushing devices to the sewers which carried their contents, untreated, into the Thames. Since drinking water continued to be extracted from the Thames, now converted into an open sewer, typhoid fever and cholera became the two principal scourges of Victorian London. During 1848/49, deaths from cholera in south London reached 1.3 per thousand as opposed to 0.37 per thousand in the upstream cleaner reaches of the Thames, with the number of deaths reaching some 6,000.

Most of the area between Rotherhithe and Lambeth was below high-water level by as much as 7 feet, and far from the sewers discharging into the Thames, the Thames was, for several hours a day, backing up into the sewage ditches. In 1849, the Commission reported that King's Mills Sewer had ten years' accumulation of sewage in it, and Paradise Row sewer was waterlogged for 20 hours a day. Both of these were in the Rotherhithe area.

In 1834, fifteen years before this situation was publicised, John Martin, a well-known painter of Biblical events and disasters, had proposed that two intercepting sewers be built below the banks of the river, to terminate at the Tower on the north, and at the Surrey Canal on the south. Two immense receptacles were to be provided, to convert the sewage into manure, and the gas was to be burnt off by huge fires,thus assisting in forced ventilation. A more formal proposal for an intercepting sewer was placed before the Commission by Cubitt and Stephenson, and one man, Joseph Bazalgette, took these suggestions seriously, noting them for future reference.

The event which pushed the Victorian legislators into taking action, and ultimately adopting Bazalgette's recommendations was the 'Great Stink' of 1858, when the combination of an unusually warm summer and an unbelievably polluted Thames made it necessary to hang sacking soaked in deodorising chemicals at the windows of the House of Commons.