I could be wrong, and if I am, please, someone correct me... but I think Google and some other search engines index the content of alt tags.
Sometimes, for design aesthetics, I have created an image of text created with fonts that are not available via HTML, but are available to Photoshop, Illustrator, etc. If you have a precise typographic impression you want to create which involves textual information, the only way to get that across is to create an image of the typographical text and put the actual text in an alt tag for the sake of search engines.
If someone has a better solution, I'd love to hear it.
Meanwhile, tho, given a need for what I have described, it would seem reasonable to me to vote for HTML inline height/width parameters, along with alt text descriptions, as a matter of standard practice. It is, in fact content, not just design in such cases -- and such cases really should not be exceptions to the rule until CSS and search engines come up with an better solution.