The above letter was referred to Dr. Cooley, who replies in this manner:
Dr. Almassi is probably right that this studio portrait of Alfred Blalock was altered, but the alteration was not made by us.
Dr. Blalock was a heavy smoker—nearly a chain smoker. Although he was right-handed, he was ambidextrous with cigarettes and could well have been holding a cigarette in his left hand. The famous studio photographer Karsh took a photograph of Dr. Blalock in which his subject was blowing smoke through his nose. This was one of Dr. Blalock's favorites.