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The word fastidious has two different (my opinion) meanings: someone 1) who pays much attention to small details and 2) who has strong dislike of anything dirty.

You can satisfy the first meaning but not the second and vice versa. For instance, someone wants everything to be correct and perfect, but would eat street food without washing his hands. And someone can live in a squalor and wash his hands 20 times a day.

If you hear "he is so fastidious," which of those meanings pops up in your mind first?

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The first meaning pops to mind first. Don't know why exactly, might be the word sounds too "old" to directly refer to modern ideas like cleanliness and hygiene. The Hygiene things feels like a newer specification of the fussiness. - Indeed the word seems to be older then the idea of hygiene. –  oerkelens May 14 at 13:54
    
Collins (UK) and (US) don't have that, nor does dictionary.com. Wiktionary has some relatively recent examples of it, but they only work because of the cotext - I wouldn't get the sense of cleanliness from it on its own. Long story short - 1. I think of one first :) –  jimsug May 14 at 13:56

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Etymonline says:

fastidious (adj.)

mid-15c., "full of pride," from Latin fastidiosus "disdainful, squeamish, exacting," from fastidium "loathing, squeamishness," most likely from *fastu-taidiom, a compound of fastus "contempt, arrogance" and taedium "aversion, disgust." Early use in English was both in passive and active senses. Meaning "squeamish, over-nice" emerged in English 1610s.

I think the distinction shouldn't be made at all. Fastidiousness is a strong dislike towards disorder - whether through lack of care in finish and arrangement, or through untidiness, dirt, and unseemly features. A fastidious person will be equally appalled at the corner of shirt sticking from under the belt as for a smudge of dirt on their hand. The differentiation between untidy and unclean is insignificant here - the dictionary definition doesn't cover two different traits, it covers two symptoms of the same trait of character.

Note the word has different connotations, starting with positive (very good attention to detail) through neutral (conditions must be fulfilled precisely) to quite negative (impossible to please, spoiled) but they are all still related to the same trait of character, which may be desirable in certain conditions and unbearable in others.

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